By Completing the below form, I give my permission to Kirk Lewis 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 Federally Facilitated Marketplace.

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