Lost Coverage Date MM slash DD slash YYYY Application ID#Date* MM slash DD slash YYYY Effective Date MM slash DD slash YYYY Agent / NPN*Please enter the agent's name. NPN is optional.Premium QuoteUS Citizen* Yes No Carrier / PlanPrimary Name*Status*MarriedSingleGender*MaleFemaleDOB* MM slash DD slash YYYY SS#Need Coverage* Yes No Spouse/Partner NameStatusMarriedSingleGenderMaleFemaleDOB MM slash DD slash YYYY SS#Need Coverage* Yes No Dependents NameGenderDOBSS#Need Coverage Physical Address*County*City*State*Zip*How long at this address?Phone #*Alternative #Personal Email Mailing Address*County*City*State*Zip*Primary EmployerSpouse EmployerIncomeIncomeWork Phone #Work Phone #Other Household IncomeAmountApplication QuestionsHow you ever been on Market Place* Yes No Does anyone in your household use tobacco?* Yes No Are you enrolled in a 401(k) program?* Yes No Do you or your spouse receive Social Security?* Yes No Are you an American Indian of Alaska Native?* Yes No If not US-born / Naturalized Citizen, do you have eligible immigration status? Yes No Document ID#*Is anyone pregnant who is applying for coverage?* Yes No Who?*Did you file a Federal Income Tax return last year?* Yes No If married, do you file joint taxed? Yes No Do you file dependents not yours on your income tax return?* Yes No How are the dependents related to you?*Would you like information on: Dental Vision Life INTERNAL USE ONLYAgentEntered By FINAL PRICINGClient Premium ActualSubsidy ActualTotal Premium ActualCarrierPlanMarketplace Requirements Primary Spouse Dependent Income Immigration Residency SS# US Citizenship Self-Employed Other RequirementDeadline (Date Due to MP)Agent NotesSTATEMENT OF UNDERSTANDING I authorize Elite Benefits Group (EBG) to act on my behalf. I understand this is a quote, and actual figures may be different. I understand that EBG will attempt to input my Healthcare.gov application from the information I have provided. I understand EBG will not audit or verify the information I provide, although it may be necessary for EBG to ask me for clarification of some of the information. In addition, Healthcare.gov may request additional information or verifications. I understand it is my responsibility to provide all of the information required. By submitting this form, I acknowledge and agree that it does not constitute enrollment or coverage. By submitting this form, I agree not to hold Elite Benefits Group, its agents or employees responsible for coverage and am granting Elite Benefits Group authority to enter the information to the best of their ability on my behalf. I certify that all statements on this form are complete and true. I understand that EBG may rescind my form for any of my acts or practices that constitute fraud or if I make an intentional misrepresentation of material fact. I understand benefits may not be available until the entire premium has been applied and coverage has been issued by the insurance carrier. I understand that the carrier will issue a health care booklet and identification card for coverage to me. The handling of premium fees by EBG does not indicate an acceptance or issuance of coverage. I understand rates upon issue may be higher than the original quoted rates. I further understand that any coverage provided by the insurance company will be subject to the provisions of the benefit booklet that is issued to me by the insurance carrier. I understand that acting on my behalf often requires the acquisition, use, and exchange of personal health information (PHI) to perform EBG's services. I understand this form and its attachments may contain privileged and confidential information and/or protected health information (PHI) and I consent to allow EBG to review, disseminate, distribute, print, copy, or otherwise use my PHI to perform those services. I understand that my agent is authorized to contact the marketplace on my behalf and that plans may change on a year to year basis. I will alert EBG with changes to marketplace information regarding updates including but not limited to change of address, job, phone #, income, marital status and dependent information. Elite Benefits Group will work as my liaison with the insurance company and the marketplace in establishing coverage and it is my responsibility to deal directly with the insurance company regarding all claims and service issues. Signature of Primary*Date* MM slash DD slash YYYY Signature of SpouseDate MM slash DD slash YYYY Signature of Agent / RepDate MM slash DD slash YYYY AUTHORIZATION FOR BANK DRAFT / CREDIT / DEBIT CARD CHARGE By signing below, I certify that I am an authorized user of this bank account and/or credit card. I understand that the bank account/credit card listed cannot by my employer's account. If I have chosen the Bank Draft Option, as a convenience to me, I hereby request and authorize Elite Benefits Group to initiate the debit to my bank account payable to the order of the insurance carrier for my first and subsequent months' premium. I also authorize my financial institution to reduce the balance of my account by the amount on each monthly draft. If I have chosen the Credit Card and Direct Billing Option, as a convenience to me, I hereby request and authorize Elite Benefits Group to charge my credit card for my first payment. I also authorize my financial institution to charge my credit card account for the credit card charge. If I have chosen the recurring Credit Card Option, as a convenience to me, I hereby request and authorize my carrier to charge the indicated credit card on a monthly basis for the amount due under my contract. I agree that if such charges be dishonored, whether with or without cause and whether intentionally or inadvertently, EBG shall have no liability whatsoever even though dishonor may result in forfeiture of insurance. I agree that my chosen payment option shall be initiated upon this application's acceptance.CLIENT PAYMENT INFORMATIONAccount Type Checking Savings Name of BankName of AccountBank Routing #Account #Automatic Monthly Draft Payment Yes No Charge my Card:Card Type Debit Credit VISA Mastercard Name on Credit/Debit CardCredit / Debit Card #Billing / Mailing Address of CardExp. DateCVVSignatureDate MM slash DD slash YYYY Authorization for EnrollmentSignature*Date* MM slash DD slash YYYY By signing above, I give Elite Benefits Group the authorization to enroll me and/or my family members listed in the health plan discussed.AUTHORIZATION FOR TEXT MESSAGING By signing this form I authorize Elite Benefits Group to send text messages to my cell phone. The text will be reminders or new products concerning health, life, dental, or medicare insurance. I understand that I would be responsible for any text messaging rates apply to any messages received from Elite Benefits Group. To stop text messages at any time, just text the word STOP.NameCell Phone NumberSignatureDate MM slash DD slash YYYY Privacy Disclaimer: Your information will not be shared or distributed in any way. Δ
