First Name *

Last Name *

Phone *

State Abbreviation *

Submitting Agent *

Submission Date *

Was an ACA policy sold? *

Yes

No

Portal Used *

Policy AOR *

FFM / Exchange ID *

Health Sherpa URL *

Health Carrier *

Health Plan Name *

Members on Plan *

Health Effective Date *

Premium Before Subsidy *

$

Subsidy Amount *

$

Premium After Subsidy *

$

Payment Method *

Bank Account

Card

Bank Account Type *

Routing Number *

Account Number *

Card Type *

Card Number *

Expiration Month *

Expiration Year *

CVV *

Billing Zip Code *

Heath Deductible *

$

Health MOOP *

$

My MFG Consent *

PDF

Was this deal a referral? *

Yes

No

Notes

Was this a clawback? *

Yes

No

Who was the original AOR? *

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 *

Who is Covered? *

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 *

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 *

Ameritas Vision Member ID *

Ameritas Vision Monthly Premium *

$

Ameritas Vision Effective Date *

Ameritas Vision Notes