New Client ACA Form

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

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 *