• Health Insurance Info Update

    Please use this form to update your information for annual enrollment. Thanks, Linsey Mills
  • Spouse & Dependent Information

    Please complete the information below if you would like coverage on your spouse and/or children.
  • Employment Information

  • Spouse's Employment Information

  • I would like more information on the following:

  • For Advisor/Agent Use Only

  • Thank You!

    By submitting, you understand this is an update of information for current clients. Elite Benefits Group will update your 2021 application from the information you have provided. We will not audit or verify the information you submit, although it may be necessary to ask you for clarification of some of the information. In addition, Healthcare.gov may request additional information or verifications. It is your responsibility to provide all of the information required. By submitting this form, you acknowledge and agree that it does not constitute enrollment or coverage. By submitting this form, you agree not to hold Elite Benefits Group, its agents or employees responsible for coverage and are granting Elite Benefits Group authority to enter the information to the best of their ability on your behalf.
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