Health Insurance Quote

Health Insurance Info Update

Please use this form to update your information for annual enrollment. Thanks, Linsey Mills
Health Insurance Agent*
Name (Legal Name)*
Date of Birth
Type DOB as MM/DD/YYYY. Example: 01/01/2018
Applicant's SS Number
Applicant's Sex

MaleFemale
Full Physical Address*
Street, City, State, Zip
County*
Full Mailing Address If Different
Street, City, State, Zip
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?

YesNo
Include Spouse in Coverage?

YesNo
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 SS Number
Spouse's Sex

MaleFemale
Is anyone applying for coverage pregnant?

YesNo
If yes, which applicant?
If not a US citizen or national, do you have eligible immigration status?

YesNo
Immigration Document #
Dependent #1 Name
Dependent #1 Sex

MaleFemale
Dependent #1 applying for coverage?

YesNo
Dependent #1 currently on Medicaid/Choice?

YesNo
Dependent #2 Name
Dependent #2 Sex

MaleFemale
Dependent #2 applying for coverage?

YesNo
Dependent #2 currently on Medicaid/Choice?

YesNo
Dependent #3 Name
Dependent #3 Sex

MaleFemale
Dependent #2 applying for coverage?

YesNo
Dependent #2 currently on Medicaid/Choice?

YesNo
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 jobsStop workingStart Working Fewer HoursNone 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 InsurangeFinal Expenses PoliciesLong Term CareDental InsuranceDisability InsuranceMedicare Supplement
For Advisor/Agent Use Only
Subsidy Eligible?

YesNo
Total Premium Quoted
Subsidy Amount Quoted
Net Premium Quoted
Carrier
Plan Design
File Attachments

Browse Files
Examples: W-2, Paystub, Immigration Card Cancelof
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.
Should be Empty:

Health Insurance Info Update

Spouse & Dependent Information

Employment Information

Spouse's Employment Information

I would like more information on the following:

For Advisor/Agent Use Only

Thank You!