Application Enrollment & Authorization

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Introduction

Applicant Name
Date of Birth
SSN
Social Security Number
State of Birth
Employer
Occupation
Time at current position
Please estimate with month or years
Are you a Tobacco User?
Chew, Cigar, Patch, Gum, Vape, Marijuana, Cigarette, etc
Height
Best time for visit of nurse for inspection
Weight
 Pounds
Driver's License Number
DL State
Issuing State of Driver's License
Have any points been added to your driver's license in last 5 Years?
Please specify
Are you married?
Spouse Name
Date Of Birth
SSN
State of Birth
Employer
Occupation
Are you a Tobacco User
Chew, Cigar, Patch, Gum, Vape, Marijuana, Cigarette, etc
Driving License Number
DL State
Issuing State of Driving License
Have any points been added to your driver's license in last 5 years?
Please specify
Height
Best time for visit of nurse for insepection
Weight
 Pounds
Do you have children under 19?
Children Info
Some Fields are missing. Please fill them to continue

Contact Details

Home Address
# Street, City, State
City
Zip Code
Email Address
Cell Number
Primary Beneficiary
Insurance Payout Recipient
Relationship
Date of birth
Street
City
State
Zip Code
Secondary Beneficiary
Insurance Payout Recipient
Relationship
Date of birth
Street
City
State
Zip Code
Some Fields are missing. Please fill them to continue

Health History

Primary Care Physician Name
Doctor's Office Phone
Full Doctor's Office Address
Street, City, State
Zip Code
Last Visit
Estimated Date is Acceptable
Additional Doctor
Specialty doctor, or for spouse
Medications & Diagnosis
Additional Chronic Health or Organ conditions?
Please Specify
Some Fields are missing. Please fill them to continue

Applicant Background

Have you ever been convicted of any Misdemeanors or Felonies in your life?
Please Specify
Has your Driver's license ever been suspending or revoked?
Speed, DUI, Point Accumulation etc
Please Specify
Do you drink alcohol on a regular basis?

Monthly Contribution Information

Bank Name
Your Bank City & State?
Routing #
9 digits in lower left hand corner of your checks
Account #
Digits on the bottom center/right of your check, do not include check number
Submit an image of your voided and signed check
Do not forget to sign and make sure image is clear
Maximum file size: 10 MB
Some Fields are missing. Please fill them to continue
Are you replacing any policies?
Carrier info
What is your maximum monthly Program Investment budget?
$
Preferred Monthly Draft Date
1st contribution drafts upon approval
Some Fields are missing. Please fill them to continue

E-Signature

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Spouse Signature optional

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Confirm Authorization

Aaron & Sarah will have your Quick Quote done.....Quickly!

Giving you the BEST INFO takes time — BUT since we’re almost super heroes, we’ll get back to you like a speeding bullet leaping tall buildings in a single freight train… or something like that?

Be on the LOOKOUT for our email coming from: aaronandsarah@thecoveragecouple.com!

Aaron & Sarah Financial Advisors