FDIA 2021 OPEN ENROLLMENT CLIENT INTAKE FORM
P.O. Box 643 • Jackson, MS 39205 • Phone: 662-402-6372 • Office:769-257-7482 • Fax: 601-500-5754 • Email: FDIA072014@gmail.com
**FOR OFFICE USE ONLY**
Date
/
Month
/
Day
Year
INS. TYPE:
AHC ID#
Insurance Type
Final Expense
LTC
Dental
Vision
AFLAC
APPLICANT BEGIN FILLING OUT THE FORM
Name
*
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Social Security Number
*
Date of Birth
*
/
Month
/
Day
Year
Residential Address
*
Apt. #
City
*
State
*
Zip Code
*
County
*
Mailing Address
Apt. #
City
State
Zip Code
Sex
Male
Female
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Age
Height
Weight
Smoker?
Yes
No
Need Coverage
Yes
No
Employment
Salary
Deduction Type
Alimony
Child Support
Student Loans
Other
Other
If you selected “Other” for the deduction type please explain?
Phone Number
-
Area Code
Phone Number
Employment
Salary
Deduction Type
Alimony
Child Support
Student Loans
Other
Other
If you selected “Other” for the deduction type please explain?
Phone Number
-
Area Code
Phone Number
Spouse
Phone Number
-
Area Code
Phone Number
Social Security Number
Date of Birth
/
Month
/
Day
Year
Sex
Male
Female
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Age
Height
Weight
Employment
Salary
Phone Number
-
Area Code
Phone Number
Employment
Salary
Phone Number
-
Area Code
Phone Number
Smoker?
Yes
No
Need Coverage
Yes
No
Do you plan to file taxes 2020-2021?
Yes
No
Additional Comments
Do you plan to file taxes 2020-2021?
Are you or your spouse on Medicare?
Yes
No
Additional Comments
Are you or your spouse on Medicare?
Are you or your spouse on Medicaid?
Yes
No
Additional Comments
Are you or your spouse on Medicaid?
Other Coverage
Losing Coverage
/
Month
/
Day
Year
LIST DEPENDENTS CARRIED ON TAXES
Name
Date of Birth
/
Month
/
Day
Year
Social Security Number
Sex
Male
Female
Need Coverage
Yes
No
Income
Name
Date of Birth
/
Month
/
Day
Year
Social Security Number
Sex
Male
Female
Need Coverage
Yes
No
Income
Name
Date of Birth
/
Month
/
Day
Year
Social Security Number
Sex
Male
Female
Need Coverage
Yes
No
Income
***OFFICE USE***
Tax Credit
Premium
Deductible
Effective Date
/
Month
/
Day
Year
Company/Plan Chosen
Completed Date
/
Month
/
Day
Year
By
Comp Acc. Created
/
Month
/
Day
Year
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FDIA Consulting Fee
$31.20
$
31.20
FDIA Consulting Fee
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Option 3
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Total
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$
0.00
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