Client Enrollment Form (Page 2 of 3) in pdf

Client Enrollment Form Page 2

SECURITY QUESTIONS: ________________________ ANSWERS: ________________________

_________________________

PLAN SELECTED: ________________________________________________________________

MONTHLY PREMIUM:___________MONTHLY SUBSIDY:_________ NET PREMIUM:_________

ENROLLMENT DATE: ___________________

EFFECTIVE DATE: _____________________

INITIAL PAYMENT MADE: Y___ DATE MADE:________ PAYMENT TYPE: CC_____ BA _____

INITIAL PAYMENT VIA: PHONE____

HC.GOV____

CARRIER WEBSITE______

CC #_______________________________ EXP DATE:__________ SEC CODE:________

BA #________________________________ ROUTING# ________________________________

CONFIRMATION #_______________________________________________________________

ELIGIBILITY REQUIREMENT?:

Y ___

N ___

IF YES, DATE DUE:_____________________

REQUIREMENT NEEDED:____________________________________________________

DATE SENT IN/ UPLOADED: _______________

FOLLOW UP LETTER SENT:

Y ___

N ___

SENT DATE: _________________________

REFERRALS FROM CLIENT:

NAME:_____________________________ PHONE:___________________ CITY____________

SOLD: Y____ N____

SOLD DATE:______________

REFERRAL FEE:______

Client Enrollment Form Page 2