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I give my permission to Pat Leyser and The Rathbun Agency to act as my legal Marketplace authorized representative, to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information and/or the personally identifiable information of my authorized representative and to perform the following duties as my agent/agency:
I understand that I may revoke this authorization at any time and will notify the Agent/Agency if I choose to revoke my authorization. My agent is not responsible for any penalties I incur as a result of misstating my projected income.
I understand the Agent/Agency has the following responsibilities and will perform the following functions:
The Rathbun Agency is an independent insurance agency located in Lansing, Michigan.
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