Application
Agent Name:
*
Chris A
Chris M
David A
Dwight W
Jennifer/Jojo - House
Lindsey S
Lisa
Mike J
Monica - House
Sara B
Shadea D
Other
Lead Source:
*
Today's Date:
*
-
Month
-
Day
Year
Date
Payment Date:
*
-
Month
-
Day
Year
Date
Effective Date:
*
-
Month
-
Day
Year
Date
Agent, please select "Next" down below
DO NOT SUBMIT
***FOR VERIFIER ONLY***
Verifier Name:
Verifier Notes:
Member ID:
Submit - FOR VERIFIER
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Primary Insured
Primary Insured:
*
First Name
Last Name
Middle Initial:
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender:
*
Male
Female
Add Members?
*
Yes
No
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Dependents
Spouse Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Age:
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Child Name:
First Name
Last Name
Gender:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
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Contact
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Email:
*
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Policy Info
Plan
HII STM
HII Limited Plans (HC/VItala/Conso)
AWIS
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HII STM
Plan:
LifeShield STM
AdvantHealth STM
Pre-Ex Rider?
Yes
No
Height:
Weight:
Max Benefit:
$250,000
$750,000
$1,000,000
Deductible:
$1,000
$2,500
$5,000
$7,500
$10,000
Coinsurance:
70/30
80/20
100/0
Max Out of Pocket:
$0
$2,000
$3,000
$4,000
$5,000
Term:
Vital AD&D
$0
$75
$100
$131.45
Freedom Spirit:
$0
$161.50
Safeguard/Sentry Accident:
Critical Illness:
Dental:
Ally Rx:
Monthly Premium:
Enrollment Fee:
$27.50 (Must be Approved)
$125
First Month Total:
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HII Limited Plans
Plan:
Health Choice+
VitalaCare
ConsoliCare
Plan Level:
100
100A
200
200+
300
500
700
750
1,000
Vital AD&D
$0
$75
$100
$131.45
Freedom Spirit
$0
$161.50
Sentry/Safeguard Accident:
Critical Illness:
Dental:
Ally Rx:
Monthly Premium:
Enrollment Fee:
$27.50
$125
First Month Total:
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AWIS
Primary Health Plan:
Plan Price:
Add-On:
Add-On Price:
Add-On:
Add-On Price:
Add-On:
Add-On Price:
Total Monthly:
Enrollment Fee:
$0 (Must be Approved)
$20 (Must be Approved)
$50 (Must be Approved)
$99 (Must be Approved)
$125
First Month Total:
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Payment Info
*
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Meds *If you do not complete this portion and the customer calls in with medication issues you are eligible for 60-day 100% chargeback*
Medication List:
*
Annual Household Income:
Notes for Verification:
Submit
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Should be Empty: