All Products forms2019-01-09T08:38:20+00:00

“By submitting this form, you certify that all of the statements in this application are true and complete and are made for the purpose of applying for Health Insurance Quotations. You authorize Health and Life Associates LLC (Provision Enrollment) to share your application and related information with its partners in order to complete the processing of this application. You are also providing express written consent to receive marketing/telemarketing communications from us and its third party associates at the phone number you provided via live, pre-recorded or auto-dialed via telephone, mobile device (including SMS and MMS) and/or email, even if your telephone number is currently listed on any state, federal or corporate Do Not Call List. You understand that consent is not a condition of purchase. Message and data rates may apply and you confirm and certify that you are at least 18 years of age.”