First Name *

Last Name *

Phone *

State Abbreviation *

• AR
• AZ
• AL
• FL
• GA
• IA
• IL
• IN
• KS
• LA
• MI
• MO
• MS
• NC
• NE
• NH
• OH
• OK
• SC
• TN
• TX
• WI
• WV
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Submitting Agent *

• Alejandro Aleman
• Alejandro Jimenez
• Alle Krever
• Brandon Nelson
• Davion Maxwell
• Dillan Gumpher
• Dominic Rizzo
• Giorgio Zambrano
• John Southard
• Kelven Jean-Louis
• Marce Bernal
• Marie Cherisme
• Milton Guerrero
• Sophia Kersten
• Stephanie Gerogianis
• Susan Vincent
• Nicholas Sylvester
• Zachary French
• Zolan Long
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Submission Date *

Was an ACA policy sold? *

Yes

No

Portal Used *

• Alejandro Aleman
• Alejandro Jimenez
• Alle Krever
• Brandon Nelson
• Davion Maxwell
• Dillan Gumpher
• Dominic Rizzo
• Frank Alfieri
• Giorgio Zambrano
• Jacob Kessel
• John Southard
• Kelven Jean-Louis
• Marcelith Bernal
• Marie Cherisme
• Milton Guerrero
• Nicholas Sylvester
• Sophia Kersten
• Stephanie Gerogianis
• Susan Vincent
• Zachary French
• Zolan Long
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Policy AOR *

• Dillan Gumpher
• Nicholas Sylvester
• Zolan Long
• Frank Alfieri
• Zachary French
• Brandon Nelson
• Davion Maxwell
• Stephanie Gerogianis
• Marie Cherisme
• Marcelith Bernal
• Alle Krever
• Jacob Kessel
• Kelven Jean-Louis
• Susan Vincent
• John Southard
• Alejandro Jimenez
• Giorgio Zambrano
• Giovanni Racine
• Myelle Clowers
• Sophia Kersten
• Milton Guerrero
• Alejandro Aleman
• No elements found. Consider changing the search query.
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FFM / Exchange ID *

Health Sherpa URL *

Health Carrier *

• Aetna
• Alliant (GA)
• Antidote
• Amerihealth Caritas
• Ambetter
• Anthem
• AvMed
• BCBS
• Caresource
• Christus
• Cigna
• Molina
• MyBlue Health Blue Cross
• Oscar
• United Healthcare
• Wellpoint
• Kaiser Permanente
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Health Plan Name *

Members on Plan *

• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10
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Health Effective Date *

Premium Before Subsidy *

$

Subsidy Amount *

$

Premium After Subsidy *

$

Payment Method *

Bank Account

Card

Bank Account Type *

• Checkings
• Savings
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Routing Number *

Account Number *

Card Type *

• Visa
• Mastercard
• Discover
• Amex
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Card Number *

Expiration Month *

Expiration Year *

CVV *

Billing Zip Code *

Heath Deductible *

$

Health MOOP *

$

My MFG Consent *

Was this deal a referral? *

Yes

No

Notes

Was this a clawback? *

Yes

No

Who was the original AOR? *

• Dillan Gumpher (NPN: 20660624)
• Zolan Jade (NPN: 21176920) AETNA ONLY
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Who was the last AOR on this clawback? *

Clawback Notes

Was an Aflac policy sold? *

Yes

No

Was a dental policy sold? *

Yes

No

Dental Application / Policy Number *

Dental Effective Date *

Dental Monthly Premium *

$

Plan Tier *

• Basic
• Core
• Elite
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Who is Covered? *

• You
• You & Your Spouse
• You, Your Spouse & Children
• You & Your Children
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Vision or Hearing? *

Yes

No

Was a accident policy sold? *

Yes

No

Accident Application / Policy Number *

Accident Effective Date *

Accident Monthly Premium *

$

Was a cancer policy sold? *

Yes

No

Cancer Application / Policy Number *

Cancer Effective Date *

Cancer Monthly Premium *

$

Was a critical illness policy sold? *

Yes

No

Critical Illness Application / Policy Number *

Critical Illness Effective Date *

Critical Illness Monthly Premium *

$

Was an Ameritas policy sold? *

Yes

No

Was an Ameritas dental policy sold? *

Yes

No

Ameritas Dental Plan *

• Care Lite
• Care Boost
• Care Complete
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Ameritas Dental Member ID *

Ameritas Dental Monthly Premium *

$

Ameritas Dental Effective Date *

Ameritas Dental Notes

Was an Ameritas vision policy sold? *

Yes

No

Ameritas Vision Plan *

• Select Vision
• Choice Vision
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Ameritas Vision Member ID *

Ameritas Vision Monthly Premium *

$

Ameritas Vision Effective Date *

Ameritas Vision Notes

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