United American Foundation

United American Foundation

United American Foundation

Glenn Gaines Client Worksheet
PRIMARY INSURED*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number

Foundation Policy Suitability Review

MMGAP
Insurance Company for Your Primary Medical Policy
Your Primary Medical Policy is

A group health plan (example: through your employer orIndividual health insuranceOther
Your Primary Medical Policy is

In force, orAn application has been submitted and the policy is in the process of being issured
* If application is in the process, what is the requested effective date?

Individual Quote Calculation

Maximum Out of Pocket Benefit
Maximum Benefit
Requested Amount
PRIMARY INSURED

First NameLast Name
Gender*
Age*
Modal Factor*
Primary Insured*
BASE PLAN ANNUAL PREMIUM x Modal Factor
Hospital*
Primary Insured (optional)*
OUTPATIENT ANNUAL PREMIUM x Modal Factor
Outpatient*
Total Premium*
PRIMARY INSURED

SPOUSE INSURED

First NameLast Name
Gender
Age
Modal Factor
Spouse Insured
BASE PLAN ANNUAL PREMIUM x Modal Factor
Outpatient
Spouse Insured (optional)
OUTPATIENT ANNUAL PREMIUM x Modal Factor
Hospital
Total Premium
SPOUSE

CHILD INSURED

First NameLast Name
Gender
Age
Modal Factor
Child Insured
BASE PLAN ANNUAL PREMIUM x Modal Factor
Hospital
Child Insured (optional)
OUTPATIENT ANNUAL PREMIUM x Modal Factor
Outpatient
Total Premium
CHILD

ADDITIONAL CHILDREN
Additional Children
Base Premium for All
Outpatient Premium for All
Total Premium
All CHILDREN

Client 's Foundation HDHP Quote

Sum totals below
Primary Insured Total
Spouse Insured Total
Children Insured Total
Client Quote
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Annual Premium
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