CONSENT FORM FOR GEORGIA ACCESS ENROLLMENT

By Completing the below form, I give my permission to Kirk Lewis with Quality Employee Benefits Agency to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Georgia State-based Exchange (Georgia Access).

Name of Primary Writing Agent: Kirk Lewis

Agent National Producer Number: 11464507

Phone Number: 423-499-2962 (office) | 423-305-2319

Email Address: Klewisins@gmail.com

Name of Agency (if applicable): Quality Employee Benefits

Owner of Agency: Kirk Lewis