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New Client ACA Form
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Agent Name:
*
First
Last
Email To:
*
Client Information
Name:
*
First
Middle
Last
DOB:
*
Gender:
*
Male
Female
Marital Status:
*
Single
Married
Dependant
*
Yes
Not
Address:
*
Address Line 1
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
State Of Birth
*
Phone Number:
*
Secondary Phone:
Email:
*
Tobacco User:
*
Yes
No
SSN:
*
Height:
*
Weight:
*
Ethnicity:
*
Employer/Occupation:
*
Household Income:
*
Employer Phone:
*
Spouse’s Information (Complete even if not taking coverage)
Full Name:
First
Middle
Last
DOB:
Gender:
Male
Female
Taking Coverage:
Yes
No
SSN:
Height:
Weight:
Ethnicity:
State Of Birth:
Dependant Information:(Complete even if not taking coverage)
First Dependant
Full Name:
First
Middle
Last
DOB:
Gender:
Male
Female
Taking Coverage:
Yes
No
SSN:
Height:
Weight:
Ethnicity:
Second Dependant
Full Name:
First
Middle
Last
DOB:
Gender:
Male
Female
Taking Coverage:
Yes
No
SSN:
Height:
Weight:
Ethnicity:
Third Dependant
Full Name:
First
Middle
Last
DOB:
Gender:
Male
Female
Taking Coverage:
Yes
No
SSN:
Height:
Weight:
Ethnicity:
Payment Information:
Name on Card
CVC
Billing Zip Code
Account #
Routing #
Plans Chosen (Note Est. Cost, Deductible & Supplemental Insurance if applicable)
I authorize Amerus Financial Group to draft the total monthly payment from the account above. Additionally, I authorize my financial institution, as identified above, to debit the same amounts from my account. I understand that this authori- zation will be in effect until I notify AFG and my bank, in writing, that I no longer desire this service.
Signature
*
Date / Time
*
Submit
