Major Medical Quick Start form

Major Medical Health Insurance:
Benefit Consultant *
Clients Full Name*

First NameLast Name
Clients Date of Birth*

MonthDayYear
Clients Full Social Security Number *
Gender Status*
Clients Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Size: If More Than Member Please Put Additional information of the Spouse and Children Information In Next Box.*

MemberMember and SpouseChild/ not on Medicaid, Chip or MediCalMore than one child / Not on Government ASSTMore than 5 Children
Notes/ Please enter Spouse and Children Names, Date of birth, and Social Security number in the box below. If not applicable please put N/A in box's (only if child is NOT on any state program such as: Medicaid, MediCal, or Chips
Picture Of Primary Insured: GOV ID, DL, Military ID, Work ID, School ID, Birth Cert/ SS card, Passport, Foreign ID, Voters ID, *

Cancelof
Member Occupation/ Self-Contractor/ Unemployment/Name*
Member Monthly Income Amount/ If $0.00 Put $0.00*
Clients Phone Number*
Email-Address*
example@example.com
Name of Doctor or Clinic
Major Medical Insurance Selection.*

Aetna HealthAmbetter HealthBlue CrossCignaHumana HealthKrieser HealthMolina HealthWellCare HealthWellPoint
Dental, Vision, or Hearing*
Life Insurance*
Name OF Insurance Enrolled*
I give my permission to Wright-Care Benefits to serve as myhealth insurance agent for myself and my entire household if applicable, forpurposes of enrollment in a Qualified Health Plan offered on the FederallyFacilitated Marketplace. By consenting to this agreement, I authorize theabove-mentioned agent to view and use the confidential information provided byme in writing, electronically, or by telephone only for the purposes of one ormore of the following1. Searching for an existing Marketplace application.2. Completing an application for eligibility and enrollmentin a Marketplace Qualified Health Plan or other government insuranceaffordability programs, such as Medicaid and CHIP or advance tax credits tohelp pay for Marketplace premiums.3. Providing ongoing account maintenance and enrollmentassistance, as necessary. 4. Responding to inquiries from the Marketplace regarding myMarketplace application.5. If you already have a Marketplace plan, you givepermission to switch you to a better plan if one is available, if you arealready on the best plan possible you are requesting Junnell Wright ( Wright-CareBenefits) to take over as your agent of record from this point forward unlessnotified of a change.6. I agree that if I am making less than 100% of the federalpoverty line that I am looking for work making at least minimum wage. I understand that the agent will not use or share mypersonal identifiable information (PII) for any purposes other than thoselisted above. The Agent will ensure my PII is kept private and safe whencollecting, starting, and using my PII for stated purposes above. I confirmthat the information I provided for entry on my Marketplace eligibility andenrollment application will be true to the best of my knowledge. I understandthat I do not have to share additional personal information about myself or myhealth with my Agent beyond what is required on the application for eligibilityand enrollment purposes. I understand that my consent remains in effect until Irevoke it, and I may revoke or notify my consent at any time by sending anemail, text, or phone call to Wright-Care Benefits at +1-877-622-5136 Name of Primary Writing Agent: Junnell WrightAgent National Producer Number: 14761754Phone Number: +1-1877-622-5136Email Address:Junnellwright@wrightcarebenefits.com *

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Major Medical Health Insurance: