Coverage Care Group

Step 01

Client Information

Who is the policyholder?

First Name

Last Name

Date of Birth

Annual Income

$

Phone

Alternate Phone

Email

Street Address

State

Zip Code

Step 02

Plan setup, billing and timing.

Carrier UHC

Agent

Plan Size

Individual Family

Payment Method

ACH Credit

Effective Date

Post Date?

Yes No

Day for plan to process

Step 03

Choose up to 2 core plans and enter each monthly premium.

Selected core plans0 / 2

Step 04

Tap each ancillary sold and enter its monthly premium.

Step 05

Life insurance interest, PAP and notes.

Interested in Life Insurance?

Yes No

Enrolled into PAP?

Yes No

P.A.P Tier

Notes

Step 06

Double-check everything, then submit.