AffordaCare Insurance Enrollment Portal

Agent's Name *

First Name

Last Name

Effective Date *

MM

DD

YYYY

Term Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Do you have other dependents you want to enroll?

Yes

No

Have you or any of your dependents been covered by anyother MEDICAL plan besides your current employer's plan within the past 12 months (this includes any other employer sponsored medical plan, Medicaid, Medicare, Champus, Tricare, etc.) *

If you answered "Yes", please fill out the rest of the questions.

No

Yes

Yes, due to COBRA.

Effective Date

MM

DD

YYYY

Term Date

MM

DD

YYYY

Who Was Covered on the Policy?

Myself

Spouse

Child(ren)

Will you or any of your dependents be covered under another MEDICAL plan while covered under this EBA plan offered by your employer? *

This includes Medicaid, Medicare, Champus, Tricare, etc.) If you answered "Yes" please answer the remaining questions.

No

Yes

Effective Date

MM

DD

YYYY

Who is covered by the policy?

Myself

Spouse

Child(ren)

Are you or any person to be insured now pregnant, an expectant parent, in the process of adopting a child or undergoing infertility treatment?

Yes

No

Are you, your spouse, or any person to be insured totally and permanently disabled and/or receiving long-term disability benefits?

Yes

No

In the last 12 months, has any proposed insured been recommended or scheduled for diagnostic testing, consultations, treatment, follow-up surgery that has not been completed?

Yes

No

Are you or any applicant over 300 lbs. if male, or over 250 lbs. if female?

Yes

No

For any of the following conditions within the last 5 years, have you or any person(s) to be insured received any abnormal test results, or medical or surgical treatment, or consulted a health care professional, r has medication been prescribed or recommended for:

Please select all that apply.

Heart disorder, excluding Mitral Valve Prolapse (MVP) or surgically corrected or closed Atrial Septal Defect (ASD)/Ventricular Septal Defect (VSD)

Coronary Artery Disease (CAD), Heart Attack or had Heart Surgery

Stroke Transient Ischemic Attack (TIA) or Carotid Artery Disease

Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

Crohn’s Disease or Ulcerative Colitis

Liver disorders or Hepatitis B or C, excluding fully recovered Hepatitis A

Kidney disorders, including kidney stones

Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Fibrotic Lung Disease or Primary

Pulmonary Hypertension

Diabetes, excluding Gestational Diabetes

Cancer or Tumor, except Basal Cell Skin Cancer

Alcoholism, Alcohol or Chemical Dependency, or Drug or Alcohol Abuse, or use disorder

Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency

Virus (HIV)

Autism Spectrum Disorders, Autism, Asperger’s Disorder, Rett’s Syndrome, Pervasive Development

Disorders or Pervasive Development Delay

Multiple Sclerosis (MS)

Tuberculosis (TB)

Any condition that resulted in: a surgery or procedure whose purpose is to promote weight-loss

Acknowledgement of Pre-Existing Conditions Policy *

By checking the box, I understand that no policy through Essential Benefit Administrators covers pre-existing conditions.

Terms & Conditions *

Read the Terms & Conditions of Use

Yes, I have read and accept the Essential Benefit Administrators.

Payment Authorization *

I hereby authorize Essential Benefit Administrators to debit my Checking Account monthly. I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Essential Benefit Administrators in writing of any changes in my account information. In addition, I agree to provide notification at least 30 days prior to the next payment date if I wish to terminate this authorization. I understand that this is an electronic transaction and these funds will be withdrawn from my bank account.

If an ACH transaction is rejected for non-sufficient funds (NSF), I understand that Essential Benefit Administrators may, at its discretion, attempt to process the charge again within 30 days. A $35 fee will be assessed for any NSF‘s or payments rejected. I acknowledge the origination of ACH transactions to my account must comply with the provisions of US law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated.

Electronic Signature *

By writing my name below, I, the policy holder certify that I am above the age of 18, and have completed this form acuratly and the best of my knowledge.

First Name

Last Name

Today's Date *

MM

DD

YYYY