Health Insurance Quote Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Social Security Number*

Number in Household *

Annual Income*

Employer*

Qualifying Life Event*

Spouse

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Name

First NameLast Name

Date of Birth

Date

Social Security Number

Seeking Coverage?*

YesNo

Dear Customer,

As a representative of Maher Insurance Group, I would like to thank you for choosing our agency for your healthcare needs. As per our recent discussions regarding your enrollment in an Affordable Care Act (ACA) plan, we would like to request your consent to enroll you in the plan effective the 1st of this coming month.

By signing this document, you are giving your Maher Insurance Group agent permission to proceed with your enrollment in the ACA plan of your choice, with a start date of the 1st of next month. Furthermore, you hereby revoke access to all other agents/agencies that have enrolled or assisted with an enrollment in the past, effective immediately. This action ensures that our agency becomes the sole agent on record for managing your healthcare coverage needs for all future enrollment years.

Please review the terms and conditions outlined below:

Enrollment Authorization: I, First Name* Last Name* hereby authorize Maher Insurance Group to enroll me in an ACA plan effective the 1st of this coming month. I understand that this enrollment will be processed in accordance with the rules and regulations set forth by the Affordable Care Act.
Revocation of Access: I hereby revoke access to all other agents/agencies that have previously enrolled or assisted with an enrollment in any healthcare plan on my behalf. Effective immediately upon the signing of this document, Maher Insurance Group agent becomes the sole agent on record for managing my healthcare coverage needs.
Responsibilities: I understand that Maher Insurance Group will act as my representative in matters related to my healthcare coverage. I agree to provide any necessary information or documentation required for the enrollment process and to keep Maher Insurance Group informed of any changes to my circumstances that may affect my eligibility or coverage.
Confirmation: I acknowledge that I have read and understood the terms and conditions outlined in this consent document. I agree to proceed with the enrollment as described herein.

By signing below, you confirm your consent to the enrollment and the revocation of access to other agents/agencies.

Signature* Date*

Thank you for entrusting Maher Insurance Group with your healthcare needs.
Sincerely,

Agency Manager
Maher Insurance Group

Health Insurance Application

Additional Members

Agency Exclusive Contract