Health Insurance Info Update
Please use this form to update your information for annual enrollment. Thanks, Linsey Mills
Health Insurance Agent
*
Mills, Linsey
Name (as it appears on Social Security card)
*
Current Physical Address
*
County
*
Full Mailing Address If Different
Mailing County
Mobile Phone
*
Personal Email Address
*
Spouse & Dependent Information
Please complete the information below if you would like coverage on your spouse and/or children.
Does Spouse have Group Coverage Available?
Yes
No
Include Spouse in Coverage?
Yes
No
Spouse's Name (as it appears on SS Card)
Spouse's Date of Birth
Type DOB as MM/DD/YYYY. Example: 01/01/2018
Spouse's Sex
Male
Female
Yes
Yes
No
Is anyone applying for coverage pregnant?
Yes
No
If yes, which applicant?
If not a US citizen or national, do you have eligible immigration status?
Yes
No
Immigration Document #
Dependent #1 Name
Dependent #1 Sex
Male
Female
Dependent #1 applying for coverage?
Yes
No
Dependent #1 currently on Medicaid/Choice?
Yes
No
Dependent #2 Name
Dependent #2 Sex
Male
Female
Dependent #2 applying for coverage?
Yes
No
Dependent #2 currently on Medicaid/Choice?
Yes
No
Dependent #3 Name
Dependent #3 Sex
Male
Female
Dependent #2 applying for coverage?
Yes
No
Dependent #2 currently on Medicaid/Choice?
Yes
No
Additional Dependents Information
Employment Information
Your Employer #1
*
Wages (before taxes)
*
Indicate amount, bi-Weekly, per month or per year
Employer Phone
*
In the past year did you...
Change jobs
Stop working
Start Working Fewer Hours
None of the above
If self-employed, how much net income (profit once business expenses are paid) will you get for 2020 or estimate 2021?
Spouse's Employment Information
Spouse's Employer #1
Spouse's Wages (before taxes)
Indicate amount, bi-Weekly, per month or per year
Spouse's Employer's Phone
I would like more information on the following:
Select all that apply
Life Insurange
Final Expenses Policies
Long Term Care
Dental Insurance
Disability Insurance
Medicare Supplement
For Advisor/Agent Use Only
Subsidy Eligible?
Yes
No
Total Premium Quoted
Subsidy Amount Quoted
Net Premium Quoted
Carrier
Plan Design
File Attachments
Notes
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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