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ACA Policy
Affordable Care Act
Is this a Florida Blue Submission?
YesNo
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

Colonial Life Policy
Product Sold
DentalVision
Individuals Covered
IndividualIndividual & SpouseIndividual & Child(ren)Individual, Spouse, & Children
Plan Eff. Date
MonthDayYear
Date

Financial
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
Debit CardCredit CardElectronic Check0 Plan
How does the customer authorize to pay?
Just the initial paymentPay Entire YearAutomatic Payments
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
Checking AccountSavings Account
Account Holder Name
Electronic Check Bank Name
Routing Number
Account Number
Any Notes or Observations to add

Insurance Submission Form