RetireMax Insurance - Health Insurance Form

To request a quote for health insurance, complete the form below.

First & Last Name*

Street Address*

City*

State*

ZIP Code*

What County do you reside in?*

Email*

example@example.com

Phone*

Date of Birth

Occupation

Within the past six months, have you used tobacco or nicotine products? *

YesNo

When is the last time?*

Desired Coverage Start Date

# of Individuals Needing Insurance

Please provide full name, gender, date of birth, and nicotine usage for all additional individuals needing coverage

Health Plan Needs

MedicalVisionDentalFertility Benefits

Referred By:

Comments

I confirm that I have added jen@retiremaxinsurance.com to my safe sender/contact list to ensure all communications are received. I understand that without doing so, some emails may be filtered into my spam or junk folder.

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of RetireMax Insurance

I give permission to Jennifer Francis to create, collect, disclose, access, maintain, use, and/or store my personally identifiable information (PII) and/or the PII of my authorized representative, to perform the following duties:

Inform me and/or my authorized representative about the full range of health coverage options and insurance affordability programs for which I’m eligible;
Help me complete my application for health coverage in a Qualified Health Plan (QHP) through the Marketplace and for insurance affordability programs;
Help me enroll in a QHP or in an insurance affordability program.

I understand that I may revoke this authorization at any time and will notify Jennifer Francis if I choose to revoke my authorization.

I understand that Jennifer Francis has the following responsibilities and will perform the following functions:

Jennifer Francis will inform me and/or my authorized representative about the full range of Marketplace health coverage options and insurance affordability programs for which I’m eligible, will help me apply for health coverage in a QHP through the Marketplace and for insurance affordability programs, and will help me enroll in a QHP or in an insurance affordability program.
Jennifer Francis will inform me of any possible conflicts of interest they might have.
Jennifer Francis can’t choose a health insurance plan for me.
Jennifer Francis is required to act in my best interest.
Jennifer Francis will follow privacy and information security standards when creating, collecting, disclosing, accessing, maintaining, storing, and/or using my PII and/or the PII of my authorized representative.
Jennifer Francis isn’t expected or required to maintain or store any of my PII and/or the PII of my authorized representative, other than this authorization form, but if Jennifer Francis does maintain or store my PII, they will follow privacy and information security standards.
I and/or my authorized representative do not need to provide Jennifer Francis contact information, unless I want Jennifer Francis to follow-up with me on applying for or enrolling into coverage. My consent to follow-up is given by providing my phone number(s) and/or e-mail address below.
I and/or my authorized representative don’t have to give Jennifer Francis more information than I and/or my authorized representative chooses to provide.
The assistance Jennifer Francis provides is based only on the information I and/or my authorized representative provide, and if the information provided is inaccurate or incomplete, Jennifer Francis may not be able to provide all the assistance available for my situation.
If Jennifer Francis is unable to assist me and/or my authorized representative, she will refer me or my authorized representative to another person who can help me or to the appropriate call center.
Jennifer Francis won’t charge me and/or my authorized representative a fee for any assistance provided.

I understand and consent*

I DO expressly consent to Jennifer Francis and/or RetireMax Corporationor the organization’s business associate(s) contacting me at the cellular/landline telephone number and email address indicated on this form via telephone and/or email to present information related to the health care and enabling services provided by Blue Cross Blue Shield of Illinois health-related products or services including health

Personal Information

Coverage Information