Terms, Conditions, and Disclosure of Information: READ CAREFULLY:

As the Primary Applicant listed on this Questionnaire, I hereby understand that by signing this Questionnaire I verify and/or agree that the information given is true and correct to the best of my knowledge and belief. I further understand that this questionnaire, and the information listed herein, constitutes a basic gathering of information intended for my Agent and its affiliated agents to better understand my specific health benefit needs (including Medicare needs) and for entry in a health benefit plan application, and IS NOT an official application for a qualified health plan.

 

I also acknowledge that this is a Privacy Notice Statement in an attempt to collect Personal Identifiable Information (PII).

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I also agree and acknowledge that I was shown health benefit coverage options that meet the minimum essential coverage as outlined under the Affordable Care Act, and thereby indemnify and hold and/or my Agent harmless from any liability relating to the health benefit package I choose to enroll in and for the benefits ultimately received from such health benefit package.

 

I hereby agree to indemnify and hold harmless Lion's Pride, its employees, agents and/or my Agent from and against any and all actions, claims, lawsuits, demands, costs, expenses, liabilities and losses, including reasonable attorney’s fees (“Claims”), which may result against me by reason of any acts or omissions of Lion's Pride, its agents, employees, or my Lion's Pride Agent in connection with, but not limited to, the benefits received from my selected health benefit package, the loss and/or mishandling of information listed in this Questionnaire.

 

By signing this acknowledgment, I hereby authorize Lion's Pride, its affiliated agents, and/or my Lion's Pride Agent to enter any and/or all information contained in this Questionnaire in any and/or all applicable online application(s) of the insurance carrier(s) for the health benefit plan selected by me as an appropriate and potential health benefit option for myself as the Primary Applicant and for any applicable Spouse Applicant and/or Dependant Applicant(s) for all benefits included in this enrollment.