Insurance Associates NW(LLC)
Personally Identifiable Information Release Form
By entering your legal last name and the last 4 digits of your Social Security # and clicking 'submit', you are allowing Insurance Associates NW, LLC to collect the following Personally Identifiable Information (PII) for you and for those whom your are requesting coverage (i.e. spouse, partner, dependents): Name, date of birth, full social security number (I typically do not capture this), physical and mailing address, phone number, email address, general income information (to help me assess your eligibility for tax subsidies), and general health information (to help me choose the best plan for you).
You may request to review your PII, or ask to have PII removed at any time by contacting Insurance Associates NW, LLC.
Our agency takes information privacy and security very seriously. Click
for our full Privacy and Security Notice.
Indicates required field
Last 4 Digits of Your SS# (Do NOT Include the Entire #)
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