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Insurance Submission Form
Submission Form for Inputters. Ext 5002
Email
example@example.com
Is this New or Renewal
Lead Source
Policy Status
Other
Total Number of Members Enrolled.
Sales Representative Name
NPN
Language
Sales Close Date
MonthDayYear
Date
Client's Name
First NameMiddle NameLast Name
Name
Is the person applying?
Gender
Client's Immigration Status
Client's Place of Birth
Client's Alien Number
Client's Green Card Number
Expiration Date
MonthDayYear
Date
Client's Phone Number
Format: (000) 000-0000.
Client's E-mail
example@example.com
Client's Address
Street Address
Apt Number
CityState
Zip CodeCountry
Client's County
Different mailing address?
Mailing Address
Street Address
Apt Number
CityState
Zip CodeCountry
D.O.B
MonthDayYear
Date
Age
How old will the customer be on the effective date of the policy.
Client's SSN
Client's Marital Status?
- Spouse's Name
  First NameMiddle NameLast Name
- S. Name
- Spouse's Phone Number
- Spouse's E-Mail Address
- Gender
- Is the person applying?
- Spouse's Immigration Status
- Spouse's Place of Birth
- Alien Number
- Green Card Number
- Expiration Date
  MonthDayYear
  Date
- D.O.B
  MonthDayYear
  Date
- Age
  How old will the customer be on the effective date of the policy.
- SSN
- Any Dependents?
- How many dependents?
- 1. Full Name
  First NameMiddle NameLast Name
- 1. Name
- 1. Relationship to Primary Policyholder
- 1. On Plan?
- 1. Gender
- 1. Immigration Status
- 1. Alien Number:
- 1. Green Card Number
- 1. Expiration Date
  MonthDayYear
  Date
- 1. Place of Birth
- 1. Cell Phone Number
- 1. D.O.B
  MonthDayYear
  Date
- 1. Age
  How old will the customer be on the effective date of the policy.
- 1. SSN
- 2. Full Name
  First NameMiddle NameLast Name
- 2. Name
- 2. Relationship to Primary Policyholder
- 2. On Plan?
- 2. Gender
- 2. Immigration Status
- 2. Alien Number:
- 2. Green Card Number
- 2. Expiration Date
  MonthDayYear
  Date
- 2. Place of Birth
- 2. Cell Phone Number
- 2. D.O.B
  MonthDayYear
  Date
- 2. Age
  How old will the customer be on the effective date of the policy.
- 2. SSN
- 3. Full Name
  First NameMiddle NameLast Name
- 3. Name
- 3. Gender
- 3. Relationship to Primary Policyholder
- 3. On Plan?
- 3. Immigration Status
- 3. Alien Number:
- 3. Green Card Number
- 3. Expiration Date
  MonthDayYear
  Date
- 3. Place of Birth
- 3. Cell Phone Number
- 3. D.O.B
  MonthDayYear
  Date
- 3. Age
  How old will the customer be on the effective date of the policy.
- 3. SSN
- 4. Full Name
  First NameMiddle NameLast Name
- 4. Name
- 4. Gender
- 4. Relationship to Primary Policyholder
- 4. On Plan?
- 4. Immigration Status
- 4. Alien Number:
- 4. Green Card Number
- 4. Expiration Date
  MonthDayYear
  Date
- 4. Place of Birth
- 4. Cell Phone Number
- 4. D.O.B
  MonthDayYear
  Date
- 4. Age
  How old will the customer be on the effective date of the policy.
- 4. SSN
- 5. Full Name
  First NameMiddle NameLast Name
- 5. Name
- 5. Gender
- 5. Relationship to Primary Policyholder
- 5. On Plan?
- 5. Immigration Status
- 5. Alien Number:
- 5. Green Card Number
- 5. Expiration Date
  MonthDayYear
  Date
- 5. Place of Birth
- 5. Cell Phone Number
- 5. D.O.B
  MonthDayYear
  Date
- 5. Age
  How old will the customer be on the effective date of the policy.
- 5. SSN
- 6. Full Name
  First NameMiddle NameLast Name
- 6. Name
- 6. Relationship to Primary Policyholder
- 6. Gender
- 6. On Plan?
- 6. Immigration Status
- 6. Alien Number:
- 6. Green Card Number
- 6. Expiration Date
  MonthDayYear
  Date
- 6. Place of Birth
- 6. Cell Phone Number
- 6. D.O.B
  MonthDayYear
  Date
- 6. Age
  How old will the customer be on the effective date of the policy.
- 6. SSN
- Affordable Care Act
- Is this a Florida Blue Submission?
- Florida Blue
- What is your e-mail?
  example@example.com
- Name of Previous Carrier
  What company was the customer previously with?
- ACA Company Name
  Please type the company name
- ACA Full Plan Name
  Please use full name shown in quoting site. This will help differentiate between similar plans.
- Network
- Medal Level
- Deductible
- Max OOP
- ACA Total Premium
  $
- ACA Subsidy
  $
- Total Client has to pay for ACA policy
  $
- ACA Plan Eff. Date
  MonthDayYear
  Date
- Reason for Enrollment
  If SEP, please provide specific reason and proof of SEP!
- Other - Please explain in notes
- Dental and Vision sold?
- Premium Amount
- Product Sold
- Individuals Covered
- Plan Eff. Date
  MonthDayYear
  Date
- Ancillary Sold?
- Premium Amount
- Client's Annual Income
  $
- Spouse's Annual Income
  $
- Client's Employer Name
- Client's Employer's Phone Number
- Spouse's Employer Name
- Spouse's Employer's Phone
- Name on Card
- Zip Code on Card
- Payment Method
- How does the customer authorize to pay?
- Pay Method: CREDIT CARD COMPANY
- Pay Method: CREDIT CARD NUMBER
- Pay Method: EXP DATE
- Pay Method: EXP DATE
- Pay Method: VCC #
- Checking or Savings Account
- Account Holder Name
- Electronic Check Bank Name
- Routing Number
- Account Number
- Any Notes or Observations to add
- Verification Department Email
  example@example.com
- Frank's Email
  example@example.com
- Sady E-mail
  example@example.com
- JC E-mail
  example@example.com
- Dana E-mail
  example@example.com
- Verification Agent
- Submitted Through Which of the Following:
- Application ID
- Marketplace User:
- Marketplace Password:
- Significant Day:
- City of Mother's Birth
- Favorite Cuisine
- Documents Needed
  Social Security Card Immigration Status Citizenship Household Income Incarceration Letter
- Documents Sent
  Social Security Card Immigration Status Citizenship Household Income Incarceration Letter
- Date Payment was Processed.
  MonthDayYear
  Date
- Checklist of Completion:
- 1
- Should be Empty:

Insurance Submission Form