Brookridge Benefits Insurance Agency, Inc.

FORM - HEALTH INSURANCE

Agent / Broker Information:

Name: Louie (Lew) Thompson, Agent / Broker

Name of Agency: Brookridge Benefits, Inc.

Local: (229) 337-4727 (or) Toll Free: (800) 297-0817

Website: www.brookridgebenefits.com

Email: info@brookridgebenefits.com

What type of Health Coverage do you have now?

Qualifing Events to Enroll in Health Insurance:

Primary Care Doctor (First & Last) (City & State)

Name * Required

Gender * Required

Phone * Required

Email * Required

Address * Required

County * Required

Birthday * Required

Social Security # * Required

Primary Applicant: Employer Name * Required

Primary Appicant: Annual Income * Required

SPOUSE / PARTNER INFORMATION

Spouse / Partner: Employer Name

Spouse / Partner: Annual Income

Spouse / Partner's Name: Are they applying for coverage?

Spouse / Partner's: Name

Spouse / Partner's: Gender

Spouse / Partner's: Date of Birth

Spouse / Partner's: Social Security #

Children / Dependents # 1

Children / Dependents # 1: Are they pplying for Coverage?

Children / Dependents # 1: Name

Children / Dependents # 1: Gender

Children / Dependents # 1: Date of Birth

Children / Dependents # 1: Social Security #

Children / Dependents # 2

Children / Dependents # 2: Are they applying for coverage?

Children / Dependents # 2: Name

Children / Dependents # 2: Gender

Children / Dependents # 2: Date of Birth

Children / Dependents # 2: Social Security #

Children / Dependents # 3

Children / Dependents # 3: Are they applying for Coverage?

Children / Dependents # 3: Name

Children / Dependents # 3: Gender

Children / Dependents # 3: Date of Birth

Children / Dependents # 3: Social Security #

Children / Dependents # 4

Children / Dependents # 4: Are they applying for Coverage?

Children / Dependents # 4: Name

Children / Dependents # 4: Gender

Children / Dependents # 4: Date of Birth

Children / Dependents # 4: Social Security #

Less Annoying CRM