CLIENT-INITIATED REQUEST

Continue Working With Jennifer

If Jennifer has been your trusted insurance agent and you would like her to continue servicing your Medicare and/or health insurance coverage through Lariat Point Advisors, you can make that request here. Simply complete the information below.

This request reflects your personal choice to continue working with Jennifer and is initiated voluntarily by you.

Client-Initiated Agent-of-Record / Agency Affiliation Request

Your Information

Please provide your basic information and insurance details.

Full Name

Insurance Carriers

Policy / Member Numbers

Your Agent

You're requesting to continue working with the agent you already know.

Jennifer E. Dafoe

Principal Agent

Lariat Point Advisors

Lariat Point LLC

NPN 3384878

Real Answers | Personal Guidance | Confident Choices

Your Request & Acknowledgment

Please review the information below before confirming your request.

I understand that I am voluntarily requesting, on my own behalf, that Jennifer Dafoe and Lariat Point LLC, doing business as Lariat Point Advisors, serve as my agent of record for my Medicare and/or health insurance coverage.

I understand that this request reflects my personal choice to continue working with Jennifer. I also understand that submitting this request does not guarantee that my insurance carrier will approve an agent-of-record or agency affiliation change, and that additional documentation or carrier requirements may apply.

I have read and acknowledge the statements above, and I voluntarily request that Jennifer Dafoe and Lariat Point Advisors serve as my insurance agent.

Additional Information

How did you contact Jennifer

Requested Effective Date

Additional Information Regarding My Request

Review & Sign

Signature

Sign Here