P1-1key-Referral Program EN – 1 Key Insurance

Referral Program

Steps to follow:

INFORM THE MEMBER THAT SONIA BEATO OF 1 KEY INSURANCE SOLUTIONS INC IS YOUR FLORIDA BLUE INSURER BROKER
ENTER THE APPLICATION IN THE HEALTH MARKET TO ENTER ALL THE INFORMATION OF THE MEMBER/s
LEAVE THE AGENT PART AND THE NPN (NATIONAL PRODUCER #) BLANK
COMPLETE THE APPLICATION IN THE HEALTH MARKET UNTIL ELIGIBILITY IS FINISHED AND YOU REACH THE PART OF CHOOSING THE PLAN DO NOT SELECT THE PLAN IN THE MARKET YOU ONLY HAVE TO INFORM US BY FILLING OUT THE ATTACHED APPLICATION
REQUEST THE FIRST PAYMENT WITH THE ORDER IF IT IS A CREDIT CARD YOU HAVE TO MARK IF IT IS A DEBIT OR CREDIT IT IS IMPORTANT TO COLLECT THE FIRST PAYMENT
FOR AUTOMATIC PAYMENTS YOU NEED A BANK ACCOUNT
PLEASE INDICATE TO YOUR CUSTOMER THAT WE WILL BE CALLING HIM TO GIVE US THE AUTHORIZATION TO ENTER THE ORDER (BY LAW YOU HAVE TO CALL)

Policy holder name:

Effective date:

Marketplace Application ID#:

Date of birth:

Email:

Last 4 digits of SSN:

Address:

APT #:

ZIP Code:

Phone number:

Marital status:

Projected Annual Family Income:

Plan:

Premium:

Number of people on your tax return:

Year tax return:

Does not qualify because it does not exceed the 2024 Federal Poverty Levels for Health Coverage (Household Size 1 Annual Income must be less than or equal to $21,870).

Does not qualify because it does not exceed the 2024 Federal Poverty Levels for Health Coverage (Household Size 2 Annual Income must be less than or equal to $29,580).

Does not qualify because it does not exceed the 2024 Federal Poverty Levels for Health Coverage (Household Size 3 Annual Income must be less than or equal to $37,290).

Does not qualify because it does not exceed the 2024 Federal Poverty Levels for Health Coverage (Household Size 4 Annual Income must be less than or equal to $45,000).

Does not qualify because it does not exceed the 2024 Federal Poverty Levels for Health Coverage (Household size greater than 4, annual income must be less than or equal to $45,000 plus an additional $7,710 per person).

HealthDentalAccidentCritical illness

Life Changes

Language:

Name of the Doctor:

Bank Information

Routing number:

Bank account only:

Automatic Payment:

Debit/Credit card info
First payment only

Cardholder name:

Billing Address:

Credit Card nmber:

Type:

Card:

Expiration Month:

Expriration Year:

Security code:

Name of the Agent:

Phone number:

Email:

Comments: