Submit Files

1. APPLICATION - Required
Please provide the full enrollment application. If the full application does not have all the information listed on the Client Information Form (CIF), then upload a CIF as well.

2. SCOPE OF APPOINTMENT (SOA) - Required
Note: You are not required to submit an SOA with Medicare Supplements, Dental/Vision/Hearing, or ancillary products.

3. VALUE-BASED ENROLLMENT (VBE) or HEALTH RISK ASSESSMENT (HRA) - Optional
Please provide a print screen confirmation with as much information as possible so we can track them.

4. MISC - Optional
Any notes/information/list of prescriptions you collected during the appointment should also be attached. We will upload everything you submit to AgencyBloc for your future reference.

Agent Name:*

First NameLast Name

Agent Email:*

Agent Email Address

Client Name:*

First NameMiddle NameLast Name

Client's Gender*

MaleFemale

Plan Effective Date:*

New Client to Your Book of Business?*

New ClientExisting Client

Did You Complete a Value Based Enrollment (VBE) or Health Risk Assessement (HRA)?*

YesNo

Individual Health Insurance (only complete this section if it's an individual health insurance file. This does not apply to Medicare)

SubsidyNo Subsidy

Lead Source:*

Secondary Lead Source:

Did You Complete a Coordination Call?

Client Email Address:

(If not available on the application)

PCP Name:

(if not available in the application)

Notes:

Client Files

Upload a File