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