The top half of this must be completed within the first five minutes of the call while qualifying the call.a
Once you get to product questions, focus on building the plan then come back once the plan is sold and finish the bottom half.
Family Size applying for coverage
*
Please Select
Single
Couple
Single with child(ren)
Couple with child(ren)
Submitting Agent Legal Name
*
First Name
Last Name
Agent Number
*
Existing Client
*
No
Yes
Physical Address
*
Street Address
Street Address Line 2
City
State Abbreviation
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Line 37 AGI before taxes for concurrent year of coverage
*
Number of Children
*
Please Select
1
2
3
4
4+
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Nickname
Phone Number
*
Please enter a valid phone number.
Was VICI phone number different?
*
No
Yes
VICI Phone Number
Please enter a valid phone number.
DOB
*
-
Month
-
Day
Year
Date
Gender on drivers license
M
F
Height
Weight
Tobacco Use
Yes
No
What's most important to you; what would you like to make sure we have taken care of by the end of this call today? (Lower monthly payments, Low max out of pocket, Specific doctors in network, Particular Medications, Pending surgery, etc.)
*
Any pre-existing health conditions, pending procedures/surgeries, or otherwise noteworthy health information about the client:
*
If not, enter N/A in this box.
Prescription(s) name, dosage, and frequency:
*
If not, enter N/A in this box.
Now that you've qualified the caller, find the custom solution. Then once the member has agreed to purchase the plan, and the application is complete on the carrier website, continue below.
Occupation
*
Rapport Notes
*
Spouse Number
Please enter a valid phone number.
Permission to text
*
Yes
No, this is a landline and any messages will be swallowed by the void.
Preferred contact method
*
Please Select
Text
Phone
email
carrier pigeon or smoke signal
Hahaha funny, but for real:
*
Please Select
phone
text
email
Best time to contact
*
Time Zone
*
Please Select
EST
CST
MST (Arizona)
PST
Other
If Other, what time zone:
*
Email
*
example@example.com
Spouse email
example@example.com
State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
Spouse Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Spouse Nickname
Spouse DOB
*
-
Month
-
Day
Year
Date
Spouse gender on drivers license
*
M
F
Spouse Height
Spouse Weight
Spouse State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
Spouse Tobacco Use
*
Yes
No
Child 1 Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Child 1 Nickname
Child 1 DOB
*
-
Month
-
Day
Year
Date
Child 1 gender on drivers license
*
M
F
Child 1 Height
Child 1 Weight
Child 1 State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
Child 2 Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Child 2 Nickname
Child 2 DOB
*
-
Month
-
Day
Year
Date
Child 2 gender on drivers license
*
M
F
Child 2 Height
Child 2 Weight
Child 2 State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
Child 3 Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Child 3 Nickname
Child 3 DOB
*
-
Month
-
Day
Year
Date
Child 3 gender on drivers license
*
M
F
Child 3 Height
Child 3 Weight
Child 3 State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
Child 4 Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Child 4 Nickname
Child 4 DOB
*
-
Month
-
Day
Year
Date
Child 4 gender on drivers license
*
M
F
Child 4 Height
Child 4 Weight
Child 4 State Born
Please Select
Alabama - AL
Alaska - AK
Arizona - AZ
Arkansas - AR
California - CA
Colorado - CO
Connecticut - CT
Washington DC - DC
Delaware - DE
Florida -FL
Georgia - GA
Hawaii - HI
Idaho - ID
Illinois - IL
Indiana - IN
Iowa - IA
Kansas - KS
Kentucky - KY
Louisiana - LA
Maine - ME
Maryland - MD
Massachusetts - MA
Michigan - MI
Minnesota - MN
Mississippi - MS
Missouri - MO
Montana - MT
Nebraska - NE
Nevada - NV
New Hampshire - NH
New Jersey - NJ
New Mexico - NM
New York - NY
North Carolina - NC
North Dakota - ND
Ohio - OH
Oklahoma - OK
Oregon - OR
Pennsylvania - PA
Rhode Island - RI
South Carolina - SC
South Dakota - SD
Tennessee - TN
Texas - TX
Utah - UT
Vermont - VT
Virginia - VA
Washington - WA
West Virginia - WV
Wisconsin - WI
Wyoming - WY
Other
More than 4 kids? List each name, gender, dob, state born, UIDs here
*
How many times a year do you see a doctor?
*
Please Select
0-2
3-4
5-11
12+
Preferred Doctor(s) or Facility:
*
If not, enter N/A in this box.
Are there alternative numbers?
Please Select
No
1
2
Ready to purchase?
*
No
Yes
What products were sold?
*
Health
Life (Not on a Health Enrollment Platform)
ACA
1 FFM
2 CA
3 CO
4 CT
5 DC
6 ID
7 KY
8 ME
9 MD
10 MA
11 MN
12 NV
13 NJ
14 NM
15 NY
16 PA
17 RI
18 VT
19 WA
AOBG Products
1 W.N. Active Care
2 W.N. Hos. Assure
3 W.N. Accident
4 Health 360 Lite
5 Health 360
6 Health 360 plus
7 Emergent Assist
8 Telemed 360
9 FSL S.C. I
10 FSL S.C. II
11 FSL S.C. III
12 FSL S.C. IV
13 Walmart HVC Rx
14 Walmart HVC Rx Plus
15 Walmart HVC Rx Max
16 Unified Choice Value
17 Unified True I
18 Unified True II
19 Unified True III
20 Unified True IV
21 Simple Scripts
22 Rx Valet
23 Surescript Rx
24 Cyberscout silver
25 Cyberscout platinum
26 MES Vision
27 Dental 360
28 Spark Dental
29 United Concordia
30 Argus Dental/Vision
31 GTL AD&D
32 Term Life 360
33 Life 360
34 Life 360 AD&D
35 Amalgamated Life
36 Security Protector
37 Unified Accident
38 Unified Critical
39 Pin Paws Plus
40 Altrua
41 W 360 (2.0) Basic
42 W 360 (2.0) Plus
43 W 360 (2.0) Preferred
44 W 360 (2.0) Premium
45 W 360 (2.0) Platinum
46 Pri. Care 360 Basic
47 Pri. Care 360 Plus
48 Pri. Care 360 Pref.
49 Pri. Care 360 Prem.
50 Pri. Care 360 Plat.
51 ABC Advantage 3
52 ABC Advantage 6
53 ABC Advantage 9
54 ABC Catastrophic
55 Dental 360 2.0
56 UVP Enhanced
57 UVP Premium
58 UVP Deluxe
59 STM 360
60 STM 360 - Child
61 Gap 5000+
62 Gap Edge +
63 Compliment Care
OptiMed Products
1 OptiMed MEC 4 Choice
2 OptiMed MEC 3 Elite
3 OptiMed MEC 2 Enhanced
4 OptiMed MEC 1 Essential
5 OptiMed IHP Premier
6 OptiMed IHP Plus
7 OptiMed IHP Basic
8 OptiMedical BasiCare
9 OptiMedical BasiCare Plus
10 OptiMedical Virtual Primary Care
11 OptiMedical Dental - Vision - Hearing Program
12 ABH Opti Dental 1000
13 ABH Opti Dental 1500
14 ABH Opti Dental 3000
15 ABH Opti Dental 5000
16 ABH Opti Plan 1000
17 ABH Opti Plan 500
18 ABH Opti Plan 300
19 ABH Opti Plan 200
20 ABH Opti Plan 100
21 EMA AcciProtect 100k
22 EMA AcciProtect 100k - 1
23 EMA AcciProtect 100K + OV
24 EMA Critical Care 2000 MAX
25 EMA Critical Care 2000 Plus
26 EMA Critical Care 2000
27 ALA OptiProtect+ 10K
28 ALA OptiProtect+ 5k
29 ALA OptiSelect+ 5K
30 ALA AcciProtect 100k
31 ALA Basic Membership
32 ABH Opti Plan 30
33 ABH Opti Plan 25
34 ABH Opti Plan 20
35 GAP Basic
36 GAP 10
37 Compliment Care
NatGen Products
1 NatG Cigna STM
2 Nat G Aetna STM
3 NatG My Life Well.
4 NatG Can. Hrt. Strk.
5 NatG Access
6 NatG H.E.P.
7 NatG Fnd. Health
8 NatG Dental PPO
9 NatG Dent. Indem.
10 NatG A/H Sel. Den.
11 NatG DVH Dental
12 NatG Sel. Copa. Den.
13 NatG Life
14 NatG Acc Fix Ben
15 NatG Acc Med Exp
16 NatG TrioMED
17 NatG TrioMED S.I.
18 NatG Crit Illness
A1 Products
ABA HI Plus
ABA HI
ABA Primary Care
Corbel Lite
Corbel Essential STM
Corbel Select STM
Corbel Deluxe STM
Bethany Basic
Bethany Essential
Bethany Choice
Bethany Elite
UHC STM Elite
UHC STM Plus
UHC STM Copay
UHC STM Value
Share Assist
Health Protect Xtra
Assurance Telecare
Wellness on the go
Advohealth Wellness
Onecare Hospital Ind.
Assure Pass Essential
Assure Pass Choice
Assure Pass Prime
Idealcare Premier
Idealcare
Idealcare Value
Focalpoint 1
Focalpoint 2
Focalpoint 3
Focalpoint 4
Focalpoint 5
Focalpoint 6
Focalpoint 7
Focalpoint 8
Apex LM
Impact Health
Pivotcare Elite
Discount Dental w/ vis
Advanced Dental
Multiflex Dental
ABA AD&D+AME+CI
ABA AD&D+AME
ABA AD&D
ABA CI
Key AME+CI+AD&D
Key AME+AD&D
Key AD&D
Evolve CI
Did you verify if Drs are in network?
*
Yes
No
W.N. Active Care Premium
*
W.N. Hos. Assure Premium
*
W.N. Accident Premium
*
Health 360 Lite Premium
*
Health 360 Premium
*
Health 360 plus Premium
*
Emergent Assist Premium
*
Telemed 360 Premium
*
FSL S.C. I Premium
*
FSL S.C. II Premium
*
FSL S.C. III Premium
*
FSL S.C. IV Premium
*
Walmart HVC Rx Premium
*
Walmart HVC Rx Plus Premium
*
Walmart HVC Rx Max Premium
*
Unified Choice Value Premium
*
Unified True I Premium
*
Unified True II Premium
*
Unified True III Premium
*
Unified True IV Premium
*
Simple Scripts Premium
*
Rx Valet Premium
*
Surescript Rx Premium
*
Cyberscout silver Premium
*
Cyberscout platinum Premium
*
MES Vision Premium
*
Dental 360 Premium
*
Spark Dental Premium
*
United Concordia Premium
*
Argus Dental/Vision Premium
*
GTL AD&D Premium
*
Term Life 360 Premium
*
Life 360 Premium
*
Life 360 AD&D Premium
*
Amalgamated Life Premium
*
Security Protector Premium
*
Unified Accident Premium
*
Unified Critical Premium
*
Pin Paws Plus Premium
*
ASH S.A. Prevent. Premium
*
ASH S.A. Access Premium
*
ASH S.A. Plus Premium
*
ASH S.A. Elite Premium
*
ASH S.A. Complete Premium
*
OptiMed MEC 4 Choice Premium
*
OptiMed MEC 3 Elite Premium
*
OptiMed MEC 2 Enhanced Premium
*
OptiMed MEC 1 Essential Premium
*
OptiMed IHP Premier Premium
*
OptiMed IHP Plus Premium
*
OptiMed IHP Basic Premium
*
OptiMedical BasiCare Premium
*
OptiMedical BasiCare Plus Premium
*
OptiMedical Vir. Pri. Care Premium
*
OptiMedical DVH Program Premium
*
ABH Opti Dental 1000 Premium
*
ABH Opti Dental 1500 Premium
*
ABH Opti Dental 3000 Premium
*
ABH Opti Dental 5000 Premium
*
ABH Opti Plan 1000 Premium
*
ABH Opti Plan 500 Premium
*
ABH Opti Plan 300 Premium
*
ABH Opti Plan 200 Premium
*
ABH Opti Plan 100 Premium
*
EMA AcciProtect 100k Premium
*
EMA AcciProtect 100k - 1 Premium
*
EMA AcciProtect 100K + OV Premium
*
EMA Critical Care 2000 MAX Premium
*
EMA Critical Care 2000 Plus Premium
*
EMA Critical Care 2000 Premium
*
ALA OptiProtect+ 10K Premium
*
ALA OptiProtect+ 5k Premium
*
ALA OptiSelect+ 5K Premium
*
ALA AcciProtect 100k Premium
*
ALA Basic Membership Premium
*
ABH Opti Plan 30 Premium
*
ABH Opti Plan 25 Premium
*
ABH Opti Plan 20 Premium
*
STM 360 Premium
*
STM 360 Child Premium
*
GAP 5000+ Premium
*
GAP Edge+ Premium
*
Compliment Care Premium
*
NatG Cigna STM Premium
*
Nat G Aetna STM Premium
*
NatG My Life Well. Premium
*
NatG Can. Hrt. Strk. Premium
*
NatG Access Premium
*
NatG H.E.P. Premium
*
NatG Fnd. Health Premium
*
NatG Dental PPO Premium
*
NatG Dent. Indem. Premium
*
NatG A/H Sel. Den. Premium
*
NatG DVH Dental Premium
*
NatG Sel. Copa. Den. Premium
*
NatG Life Premium
*
NatG Acc Fix Ben Premium
*
NatG Acc Med Exp Premium
*
NatG TrioMED Premium
*
NatG TrioMED S.I. Premium
*
NatG Crit Illness Premium
*
Altrua Premium
*
Altrua Extra Care Premium
*
Pri. Care 360 Basic Premium
*
Pri. Care 360 Plus Premium
*
Pri. Care 360 Preferred Premium
*
Pri. Care 360 Premium Premium
*
Pri. Care 360 Platinum Premium
*
W 360 (2.0) Basic Premium
*
W 360 (2.0) Plus Premium
*
W 360 (2.0) Preferred Premium
*
W 360 (2.0) Premium Premium
*
W 360 (2.0) Platinum Premium
*
ABC Advantage 3 Premium
*
ABC Advantage 6 Premium
*
ABC Advantage 9 Premium
*
ABC Catastrophic Premium
*
Dental 360 2.0 Premium
*
UVP Enhanced Premium
*
UVP Premium Premium
*
UVP Deluxe Premium
*
AOBG Member ID
*
Filing Taxes for concurrent year of coverage?
*
Yes
No
How are they filing taxes?
*
Single
Jointly
Separately (not eligible for subsidies)
What is their QLE/SEP?
ACA Carrier
*
Please Select
ACA (Other)
Aetna
Alliant Health Plans
Ambetter
Anthem Blue Cross and Blue Shield
Caresource
Cigna
Common Ground Healthcare Cooperative
Community Health Choice
Excellus BCBS NY
FirstCare Health Plans
Friday Health Plans
Health Alliance
HealthKeepers, Inc.
Highmark Benefits Group Inc.
Horizon Healthcare Services, Inc.
Kaiser Permanente
Medica
Molina Marketplace
Montana Health Cooperative
Optima Health
Oscar
Piedmont Community HealthCare HMO, Inc.
Priority Health
Salvasen Health
Sanford Health Plan
Scott and White Health Plan
UnitedHealthcare
University of Utah Health Plans
UPMC Health Options, Inc.
US Health & Life
Vantage Health Plan
Wellmark Health Plan of Iowa, Inc.
ACA Plan selected
*
ACA Subsidy
*
ACA Net Premium
*
FFM Application ID
*
Beneficiary Relationship
*
Spouse
Domestic Partner
Child
Grandchild
Parent
Brother
Sister
Cousin
Niece
Nephew
Estate
Friend
Other
Beneficiary Name
*
Beneficiary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Beneficiary Phone
Please enter a valid phone number.
Beneficiary DOB
-
Month
-
Day
Year
Date
WNAC Coverage Level
*
Please Select
5,000
10,000
20,000
30,000
40,000
50,000
WNAC Base Coverage
*
Please Select
Cancer
Heart/Stroke
Cancer and Heart/Stroke
Critical Illness
WNAC Riders
*
Critical Conditions
Hospital Indemnity
Radiation and Chemotherapy
Accident
None
WNAC Are they outside the appropriate height weight?
*
Yes
No
WNHA Are they outside the appropriate height weight?
Yes
No
WNHA Hospital Confinement Benefit Option:
*
Please Select
1,000
2,000
3,000
4,000
5,000
WNHA Supplemental Benefits
*
Yes
No
WNHA Level
*
Please Select
1
2
3
WNHA Wellness and Diagnostic
*
Yes
No
Health 360 Lite Coverage Period Max
*
Please Select
250,000
500,000
1,000,000
Health 360 Lite Copay Limit/Amount
*
Please Select
Unlimited - $25/$40
2 - $24/$40
Health 360 Lite duration
*
Please Select
6 Months
364 Days
Health 360 Lite Deductible
*
Please Select
500
1,000
2,000
2,500
5,000
7,500
10,000
Health 360 Plus
*
No
Yes
Health 360 Coverage Period Max
*
Please Select
250,000
500,000
1,000,000
Health 360 duration
*
Please Select
6 Months
364 Days
Health 360 Deductible
*
Please Select
500
1,000
2,000
2,500
5,000
7,500
10,000
Health 360 Plus
*
No
Yes
Argus HD Smart Choice Dental
*
Please Select
Member - Value
Member Spouse - Value
Member Child(ren) - Value
Family - Value
Member - Standard
Member Spouse - Standard
Member Child(ren) - Standard
Family - Standard
Member - Preferred
Member Spouse - Preferred
Member Child(ren) - Preferred
Family - Preferred
GTL AD&D
*
Please Select
Member - 50,000
Member - 100,000
Member - 200,000
Member - 300,000
Member Plus Spouse - 50,000
Member Plus Spouse - 100,000
Member Plus Spouse - 200,000
Member Plus Spouse - 300,000
Member Plus Child(ren) - 50,000
Member Plus Child(ren) - 100,000
Member Plus Child(ren) - 200,000
Member Plus Child(ren) - 300,000
Family - 50,000
Family - 100,000
Family - 200,000
Family - 300,000
STM 360 Coinsurance
*
Please Select
80/20
50/50
STM 360 Duration
*
Please Select
6 Months
364 Days
STM 360 Deductible
*
Please Select
$2,500
$5,000
$10,000
STM 360 Child Coinsurance
*
Please Select
80/20
50/50
STM 360 Child Duration
*
Please Select
6 Months
364 Days
STM 360 Child Deductible
*
Please Select
$2,500
$5,000
$10,000
Life Insurance Carrier
*
Life Insurance Face Amount
*
Life Insurance Premium
*
Life Insurance Payment Schedule
*
Please Select
Monthly
Quarterly
Semi-Annually
Annually
MHGPhone Notes
*
Have you sold them on the next appointment?
*
Yes
No
When is the follow-up appointment scheduled?
*
Is any part of this application a post date?
*
No
Yes
Which products need to be post dated?
*
What date should the payment(s) run?
*
-
Month
-
Day
Year
Date
Active Date
*
-
Month
-
Day
Year
Date
Initial Payment Date
*
-
Month
-
Day
Year
Date
Recurring Payment Date
*
Please Select
25
10
1
2
3
4
5
6
7
8
9
11
12
13
14
15
16
17
18
19
20
21
22
23
24
26
27
28
29
30
31
Copy/Paste confirmation screen here:
*
Mailing Address (if different)
Street Address
Street Address Line 2
City
State Abbreviation
Postal / Zip Code
Billing Address (if different)
Street Address
Street Address Line 2
City
State Abbreviation
Postal / Zip Code
What made you reach out for coverage today; Did we accomplish your goal?
*
Was this a referral?
*
Y
N
Did you generate this referral?
*
Yes
No, this was a MHG referral assigned to me
Lead Source
*
Please Select
MHG Renewal
CIA Shield
TEAI
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
AA
AB
AC
AD
AE
AF
AG
AH
Name & phone/email of person who referred client so we can thank them.
*
Did you explain & send Glic? https://glicrx.com/enrollmentcenter/13d51bab
*
Y
N
Are you sure you want to miss out on your combo bonus?
*
Y
I'll explain it now, so I can change the above answer to Yes
Was there a TO on this call?
*
Yes
No
Who TOed?
*
Please Select
Lavar Bennett
Mike Cardoso
Michael Hyer
Paige Kortan
On a scale of 1 to 10, 10 being the greatest, how would you rate your experience with us today?
*
Please Select
1
2
3
4
5
6
7
8
9
10
That's Fantastic!
You will be getting an email to our google business page, if you feel like I've earned it and it's not too much trouble to ask, would you mind leaving a review about the five star service you received today? It helps others like you find the same level of service and care, and it would mean a lot to me as well. Or if you're in a position to right now, go ahead and visit www.reviewmhg.com it's simple, quick, and easy. It was my pleasure serving you today.
What could we have done to improve your experience and earn that 10?
*
Did you get an introduction on this call?
*
Yes
No
Did they sent the text introduction? "I was able to get really good health insurance today by talking to my agent _____. I’ll have them reach out to you so you can take a look too."
*
Yes
No
Introduction Name
*
First Name
Last Name
Introduction Phone
*
Please enter a valid phone number.
Introduction Email
example@example.com
Introduction Time Zone
*
Please Select
EST
CST
MST
PST
Other
Introduction Preferred Contact Time
*
Introduction Preferred Contact Method
*
Please Select
Text
Phone
Email
Please verify that you are human
*
Submit
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