Elite Benefits Group Health Insurance Quote (Agent Ed Squires)
Please use this form to begin enrollment for an Affordable Care Act policy.
Health Insurance Agent
*
Please Select
Ed Squires
Have you ever created a Healthcare.gov login?
*
Please Select
Yes
No
Do you currently have health insurance coverage?
*
Please Select
Yes
No
Applicant Name (as it appears on Social Security card)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Mailing Address (If different from physical address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Mailing Address
Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Applicant Gender
*
Please Select
Male
Female
Have you frequently used tobacco products in the past 4 months
*
Please Select
Yes
No
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Applicant Estimated Annual Income
*
Applicant Employer
*
Applicant Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse & Dependent Information
Please complete the information below if you would like coverage on your spouse and/or children.
Spouse Name (as it appears on Social Security card)
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Gender
Please Select
Male
Female
Does Spouse have Group Coverage Available?
Please Select
Yes
No
Include Spouse in Coverage?
Please Select
Yes
No
Has spouse frequently used tobacco products in the past 4 months
Please Select
Yes
No
Spouse Estimated Annual Income
Spouse Employer
Spouse's Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Tax Filing Information
Do you plan to file a tax return?
Please Select
Yes
No
If married, filing jointly?
Please Select
Yes
No
Is anyone applying for coverage pregnant?
Please Select
Yes
No
If yes, which applicant
If not a US citizen or national, do you have eligible immigration status?
Please Select
Yes
No
Immigration Document #
Is anyone applying for coverage American Indian?
Please Select
Yes
No
Do you need help paying for medical bills from the last 3 months?
Please Select
Yes
No
Are you a full-time student?
Please Select
Yes
No
Dependent Info
Dependent #1 Name
Dependent #1 Gender
Please Select
Male
Femaie
Dependent #1 Date of Birth
-
Month
-
Day
Year
Date
Dependent #1 Applying for Coverage?
Please Select
Yes
No
Dependent #2 Name
Dependent #2 Gender
Please Select
Male
Femaie
Dependent #2 Date of Birth
-
Month
-
Day
Year
Date
Dependent #2 Applying for Coverage?
Please Select
Yes
No
Dependent #3 Name
Dependent #3 Gender
Please Select
Male
Femaie
Dependent #3 Date of Birth
-
Month
-
Day
Year
Date
Dependent #3 Applying for Coverage?
Please Select
Yes
No
I would like more information on the following (Select All That Apply):
Life Insurance
Dental
Vision
Medicare
Additional Information
Thank You and Disclosure:
By submitting this form, you acknowledge that any quotes or premium estimates provided are preliminary and actual premiums, subsidies, eligibility, and coverage amounts may vary based on the final application review and verification process through HealthCare.gov or other applicable agencies.You authorize Elite Benefits Group, Inc. to assist with entering and submitting your HealthCare.gov application using the information you provide. Elite Benefits Group, Inc., its agents, and employees rely on the accuracy and completeness of the information submitted by you and do not independently audit or verify such information. We may contact you for clarification or additional details if needed.You understand that HealthCare.gov or other agencies may require additional documentation, verification, or information to determine eligibility for coverage or financial assistance. You are solely responsible for providing all required information and responding to verification requests in a timely manner.Submission of this form does not guarantee enrollment, coverage approval, financial assistance eligibility, or issuance of any insurance policy. Coverage is not effective unless and until confirmed by the applicable insurance carrier or Marketplace.By submitting this form, you acknowledge and agree that Elite Benefits Group, Inc., its agents, and employees are not responsible for eligibility determinations, subsidy calculations, coverage decisions, application errors resulting from inaccurate or incomplete information provided by you, or actions taken by HealthCare.gov, insurance carriers, or government agencies.Fixed insurance products and related services may be offered through Elite Benefits Group, Inc.By providing your contact information and submitting this form, you consent to receive calls, emails, and text messages from Elite Benefits Group, Inc. regarding your application, coverage options, account updates, and other relevant information. Message and data rates may apply. Consent is not a condition of purchase.
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