Referral - CityCom Health

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Agreement – Submission of Information

I understand CityCom Health is not a licensed insurance agency. I authorize CityCom Health to provide the personal identifiable information (“PII”) I have provided to its affiliate CityCom Insure, a licensed insurance agency.

Agreement – Agency Authorization and Use of Personal Identifiable Information (“PII”)

I authorize CityCom Insure and its licensed agents ("CityCom Insure") to serve as insurance agent(s) for myself and my household. I authorize CityCom Insure to store and transmit my PII for any task related to managing any enrollment in a health insurance plan, completing any insurance application on my behalf, and performing any other tasks required as my insurance agent or requested by me. This authorization will start on the date identified below and remain valid for 30 months. I may revoke this consent at any time by emailing [email protected] or by calling 1 (866) 459-9392, or by writing to 3710 Corporex Park Dr. Suite 105 Tampa, FL 33619 . I authorize and direct CityCom Insure to verify my PII through Experian Information Solutions, Inc., including providing 'written instructions' to Experian authorizing them to obtain and verify my information to confirm my identity. The PII and other information I provide will be true, complete and accurate to the best of my knowledge. I can access information about my privacy rights through CityCom Insure’s Privacy Notice, which is available at www.citycomhealth.com. A link to the Privacy Notice will be provided to me by CityCom Insure. I can obtain a copy of this authorization by sending a request for a copy to which is also identified in the Privacy Notice.

Agreement – Contact by Agency

I consent and agree to receive phone calls, emails and SMS/text messages from CityCom Insure and its agents, for the purpose of managing my insurance needs and for any other related marketing opportunities. This consent authorizes CityCom Insure to contact me through auto-dialed and prerecorded systems. I understand that message and data rates may apply. This consent will continue until I revoke it, and I can revoke my consent at any time and by calling 1 (866) 459-9392, or by emailing [email protected] This consent supersedes any prior request to be placed on any federal, state, local, or corporate "Do Not Call" lists (if any).

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Agreement – Submission of Information

Agreement – Agency Authorization and Use of Personal Identifiable Information (“PII”)

Agreement – Contact by Agency

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