New Accounts - Health Insurance

Health Insurance Submission
Rep Information:
Agent:*
Secondary Agent*
Enrolling Agent*
Split Rep?*

YesNo
Split Percentage*
Client Information:
Existing Client*

YesNo
If yes, what is their current coverage?*
Client Name:*

First NameMiddle NameLast Name
Health Ins Details:
Coverage Type:*

ACAShort Term Major MedicalMedicare SupplementMedicare AdvantagePDPDental/VisionMedigap
ACA Company:*
ACA Monthly Premium*
Short Term Company*
Med Supp Company*
Med Supp Plan:*
Med Advantage Company*
Med Advantage Plan:*
E.g. PPO Edge $0 Month
PDP Company*
PDP Plan:*
E.g. Value $7.60 Month
Dental Vision Company*
Medigap Company*
Total Annual Premium*
Notes:
E.g. Any Health Care Issues, Client mtg notes.

Health Insurance Submission