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<div class="card plan-card mb-4">
    <div class="card-body">
        <div class="plan-title row">
            <div class="col-sm-12 col-md-9">
                <h4><%-Name%></h4>
                <div><small>Policy duration: <%-BenefitPeriod%></small></div>
            </div>
            <div class="col-sm-12 col-md-3">
                <a data-plan-issuer="<%-PlanIssuer%>" data-plan-number="<%-Number%>" data-plan-id="<%-PlanID%>" data-product-id="<%-ProductID%>" data-quote-id="<%-QuoteID%>" data-bundle-id="<%-BundleID%>" data-plan-cost="<%=MonthlyPayment.toString().replace(/\$/gi, '')%>" data-bound="0" class="enroll-plan btn btn-lg btn-primary" href="javascript:void(0)" role="button">Apply Now</a>
            </div>
        </div>
        <div class="plan-cost row align-items-end">
            <div class="col-12">
                <div>Monthly Cost</div>
                <h3 class="monthly-cost">$<%-parseFloat(MonthlyPayment).toFixed(2)%></h3>
            </div>
        </div>
        <div class="plan-cost row align-items-end">
            <div class="col-sm-12 col-md-4">
                <div>Deductible</div>
                <h3 class="other-cost"><%-Deductible.toString().toDollar()%></h3>
            </div>
            <div class="col-sm-12 col-md-4">
                <div>Coinsurance</div>
                <h3 class="other-cost"><%-Coinsurance%></h3>
            </div>
            <div class="col-sm-12 col-md-4">
                <div>Out of Pocket</div>
                <h3 class="other-cost"><%-OutOfPocket.toString().toDollar()%></h3>
            </div>
        </div>
    </div>
    <div class="card-footer text-muted">
        <div class="row">
            <%if (EnrollmentFee && EnrollmentFee > 0) { %>
            <div class="col-6"><small>One-time enrollment fee: $<%-EnrollmentFee.replace('.0000', '').replace('.00', '')%></small></div>
            <div class="col-6 text-right">
            <% } else { %>
            <div class="col-12 text-right">
            <% } %>
            <a href="https://marketplace.healthedeals.com/ViewApp/GetBrochure/STS/<%-PathToBrochure%>" class="detail-url" target="_blank"><i class="fa fa-reorder"></i> details</a></div>
        </div>
    </div>
</div>
</div>

<div class="card plan-card plan-card-ng mb-4">
    <div class="card-body">
        <div class="plan-title row">
            <div class="col">
                <h4><%-DisplayName%></h4>
            </div>
        </div>
        <div class="row">
            <div class="plan-benefits col-6">
                <div class="row">
                    <div class="col-sm-12 col-md-6">
                        Deductible
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <%-Deductible.toString().toDollar()%>
                    </div>
                </div>
                <div class="row">
                    <div class="col-sm-12 col-md-6">
                        Coinsurance
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <%-Coinsurance%>%
                    </div>
                </div>
                <div class="row">
                    <div class="col-sm-12 col-md-6">
                        Out of Pocket
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <%-CoinsuranceMaximumOOP.toString().toDollar()%>
                    </div>
                </div>
                <div class="row d-none">
                    <div class="col">
                        <a href="<%-PathToBrochure%>" class="detail-url" target="_blank"><small><i class="fa fa-bars"></i> Plan Details</small></a>
                    </div>
                </div>
                <div class="row pt-4">
                    <div class="col">
                        <a href="<%-ProviderLink%>" target="_blank"><small><i class="fa fa-user"></i> Find Doctors</small></a>
                    </div>
                </div>
            </div>
            <div class="col-6 text-right">
                <%var monthlyCost = parseFloat(TotalRate).toFixed(2),
                monthlyCostDisplay = monthlyCost.toString(),
                index = monthlyCostDisplay.indexOf('.');%>

<span class="monthly-cost">$<%=monthlyCostDisplay.substring(0, index)%><sup><span><%=monthlyCostDisplay.substring(index)%></span></sup>
                </span><small>/mo</small>
                    <a tabindex="-1" role="button" class="popover-with-selector" data-popover-selector="#monthly-cost-<%-PlanKey%><%-ProductCode%>" title="Premium Breakdown"><i class="fa fa-question-circle-o"></i></a>
                <div>
                    <small class="text-secondary">One-time enrollment fee: $<%-EnrollmentFee%></small>
                </div>
                <a data-plan-issuer="<%-PlanIssuer%>" data-plan-key="<%-PlanKey%>" data-product-code="<%-ProductCode%>"
                   data-plan-cost="<%=Rate.toString().replace(/\$/gi, '')%>" data-bound="0"
                   class="enroll-plan btn btn-lg btn-primary" href="#" role="button">Apply Now</a>
                </div>
            </div>
        </div>
        <div id="monthly-cost-<%-PlanKey%><%-ProductCode%>" class="ng-monthly-cost-breakdown d-none">
            <div class="popover-body-ng-breakdown">
                <div class="row">
                    <div class="col-sm-12 col-lg-8">Base rate</div>
                    <div class="col-sm-12 col-lg-4 text-right">$<%- parseFloat(InsuranceRate).toFixed(2) %></div>
                </div>
                <%if (AssociationFee && AssociationFee > 0) { %>
                <div class="row">
                    <div class="col-sm-12 col-lg-8">Monthly association fee</div>
                    <div class="col-sm-12 col-lg-4 text-right">$<%- AssociationFee %></div>
                </div>
                <%}%>
                <div class="row">
                    <div class="col-sm-12 col-lg-8">Monthly Premium</div>
                    <div class="col-sm-12 col-lg-4 text-green text-right">$<%- monthlyCost %></div>
                </div>
                <div class="row">
                    <div class="col-sm-12 col-lg-8">One-time enrollment fee</div>
                    <div class="col-sm-12 col-lg-4 text-warning text-right">$<%-EnrollmentFee%></div>
                </div>
            </div>
        </div>
    </div>
</div>

Tobacco

Has anyone applying for coverage smoked cigarettes or used any tobacco products regularly?

Effective Date

Per the HHS rule governing short term limited duration coverage, short term medical policy purchases are limited to a maximum duration of 90 days. You may be eligible to apply for a new policy after your current policy expires (subject to regulations in certain States).

Effective Date

Pick a date between and that you would like the plan coverage to start

Select your county

Your zip code has multiple counties. Please select the county that you live in.

Contact Info

we are loading your info

<div class="card">
                <div class="card-body">
                    <div class="form-group row">
                        <label for="contact-info-first" class="col-sm-12 col-md-4 col-form-label">First Name</label>
                        <div class="col-sm-12 col-md-8">
                            <input name="first_name" type="text" class="form-control" id="contact-info-first" required value="<%-first_name%>" maxlength="200">
                        </div>
                    </div>
                    <div class="form-group row">
                        <label for="contact-info-last" class="col-sm-12 col-md-4 col-form-label">Last Name</label>
                        <div class="col-sm-12 col-md-8">
                            <input name="last_name" type="text" class="form-control" id="contact-info-last" required value="<%-last_name%>" maxlength="200">
                        </div>
                    </div>
                    <div class="form-group row mt-4">
                        <label class="contact-info-address1 col-sm-12 col-md-4 col-form-label">Address</label>
                        <div class="col-sm-12 col-md-8">
                            <div class="mb-2"><input name="address1" type="text" class="form-control" id="contact-info-address1" required value="<%-street%>" maxlength="200"></div>
                            <div><input name="address2" type="text" class="form-control" value="<%-unit%>" maxlength="10"></div>
                        </div>
                    </div>
                    <div class="form-group row">
                        <label for="contact-info-city" class="col-sm-12 col-md-4 col-form-label">City</label>
                        <div class="col-sm-12 col-md-8">
                            <input name="city" type="text" class="form-control" id="contact-info-city" required value="<%-city%>" maxlength="100">
                        </div>
                    </div>
                    <div class="form-group row">
                        <label class="col-sm-12 col-md-4 col-form-label">State</label>
                        <div class="col-sm-12 col-md-8">
                            <p class="contact-info-state form-control-static"><%-state.toUpperCase()%></p>
                            <input name="state" value="<%-state%>" type="hidden">
                        </div>
                    </div>
                    <div class="form-group row">
                        <label class="col-sm-12 col-md-4 col-form-label">Zipcode</label>
                        <div class="col-sm-12 col-md-8">
                            <p class="contact-info-zipcode form-control-static"><%-zip_code%></p>
                            <input name="zip_code" value="<%-zip_code%>" type="hidden">
                        </div>
                    </div>
                </div>
            </div>
            <div class="card mt-3">
                <div class="card-body">
                    <div class="form-group row">
                        <label for="contact-info-email" class="col-sm-12 col-md-4 col-form-label">Email</label>
                        <div class="col-sm-12 col-md-8">
                            <input name="email_address" type="email" class="form-control auth-user-email" id="contact-info-email" required value="<%-email_address%>">
                            <div class="agent-only-view"><small>enter client's email address</small></div>
                            <div class="user-only-view"><small>this is the contact email address submitted to the insurance company</small></div>
                        </div>
                    </div>
                    <div class="form-group row">
                        <label for="contact-info-phone" class="col-sm-12 col-md-4 col-form-label">Phone</label>
                        <div class="col-sm-12 col-md-8">
                            <input name="phone" type="text" class="form-control" id="contact-info-phone" required value="<%-phone%>">
                        </div>
                    </div>
                </div>
            </div>

Please fill out your information

Invalid email address

Oops, this email address has been previously registered. But you can:

Choose a different email address as a new account

Go back to login and recover your password if you have forgotten it.

Create Account (Optional)

Already have an account? Please

Save your progress

You can save multiple applications, view and edit your information on file

If you need to modify birth date, gender, relationship, tobacco usage or add another person, click here. Modifications could result in a change in pricing of the quote.

Applicants

<% _.each(applicants, function(n, i) { %>
            <div class="applicant-card card mb-4">
                <div class="card-header">
                    <button type="button" class="remove-applicant close" aria-label="Close">
                        <span aria-hidden="true">×</span>
                    </button>
                    <h5 class="person-title">
                        Applicant <span class="counter"><%= i %></span>
                    </h5>
                    <h5 class="person-title person-title-primary d-none">
                        Primary Applicant
                    </h5>
                </div>
                <div class="card-body">
                    <div class="row">
                        <div class="form-group col-sm-12 col-md-6">
                            <label>First Name
                            <input name="first_name_0" type="text" class="form-control" value="<%- n.first_name %>" required></label>
                        </div>
                        <div class="form-group col-sm-12 col-md-6">
                            <label>Last Name
                            <input name="last_name_0" type="text" class="form-control" value="<%- n.last_name %>" required></label>
                        </div>
                    </div>
                    <div class="row">
                        <div class="form-group col-sm-12 col-md-6">
                            <%var bday = '';
                            if (n.birth_date) {
                                birth_date = new Date(n.birth_date)
                                year = birth_date.getFullYear();
                                month = birth_date.getMonth() + 1;
                                day = birth_date.getDate();
                                bday = month + '/' + day + '/' + year;
                            }%>
                            <label>Birth Date</label>
                            <div class="birth-date-text"><i><%- bday %></i></div>
                            <div class="d-none">
                                <select name="birth_date_mm_0">
                                    <option value="<%- month %>" selected></option>
                                </select>
                                <select name="birth_date_dd_0">
                                    <option value="<%- day %>" selected></option>
                                </select>
                                <select name="birth_date_yyyy_0">
                                    <option value="<%- year %>" selected></option>
                                </select>
                            </div>
                        </div>
                        <div class="twin-radio-group form-group col-sm-12 col-md-6">
                            <label>Gender</label> <div class="gender-text"><i><%if (n.gender === 'F') { %>Female<% } else { %>Male<% }%></i></div>
                            <div class="d-none btn-group btn-toggle">
                                <button class="btn btn-lg btn-white btn-check" data-value="M">Male</button>
                                <button class="btn btn-lg btn-white btn-check" data-value="F">Female</button>
                            </div>
                            <span class="d-none">
                            <input name="gender_0" type="text" class="twin-radio-value" value="<%- n.gender %>" required>
                            </span>
                        </div>
                    </div>
                    <div class="row">
                        <div class="form-group col-sm-12 col-md-6">
                            <label>Social Security Number</label>
                            <input name="ssn_0" type="text" class="form-control" value="<%- n.ssnumber %>">
                        </div>
                        <div class="form-group col relationship-col">
                            <label>Relationship</label>
                            <select name="relationship_0" class="d-none" required>
                                <option value="">Choose...</option>
                                <option value="0"<%= n.relationship == 0 ? 'selected' : void 0 %>>Primary</option>
                                <option value="1"<%= n.relationship == 1 ? 'selected' : void 0 %>>Spouse</option>
                                <option value="2"<%= n.relationship == 2 ? 'selected' : void 0 %>>Dependent</option>
                            </select>
                            <div>
                            <span class="relationship-text"><i>
                                <% if (n.relationship === 0) { %>
                                Primary
                                <% } else if (n.relationship === 1) { %>
                                Spouse
                                <% } else { %>
                                Dependent
                                <% } %>
                            </i></span>
                            </div>
                        </div>
                    </div>
                    <div class="row smoker-col">
                        <div class="col">
                            <% if (n.smoker == true) { %>
                            <div class="row form-group">
                                <div class="col">
                                    <label>What was the date that you have last used tobacco?</label>
                                    <input type="date" name="smokerdate_0" class="form-control col-xs-12 col-md-6" required>
                                </div>
                            </div>
                            <% } else { %>
                            <i class="fa fa-times text-danger"></i>
                            <i>Has not regularly used tobacco within the past six months</i>
                            <% } %>
                            <input name="smoker_0" type="checkbox" class="d-none" value="1"<%= n.smoker == true ? ' checked' : void 0 %>>
                        </div>
                    </div>
                </div>
            </div>
            <% }); %>

You did not enter information for the applicant

Eligibility Questions

Please answer the following medical questions for all individuals, including dependents, applying for coverage

Please be aware that any misstatements and omissions may be a material misrepresentation and a basis for rescission of your coverage. In the event of a rescission; (1) coverage will be void as of the Effective Date; (2) all premiums paid will be refunded; (3) any claims that have been submitted will be denied; (4) if any claims have been paid, the amount of claims paid will be deducted from any premium refund due.

loading eligibility questions

Sorry, based on your answers, coverage cannot be issued. Thank you for your interest.

Please check if you have answered the above questions.

Oops! Something went wrong. Please contact us and one of our agents can help you pick a plan.

<div class="form-group<% if (IsMainQuestion === true) { %> pb-4<% } %>">
                <% if (IsMainQuestion === true) { %>
                <div class="row">
                    <div class="col-sm-12 col-md-9">
                        <label class="control-label">
                            <% if (IsRequired) { %>
                            <span class="text-pink">*</span>
                            <% }%>
                            Question <%- Number%>
                        </label>
                    </div>
                    <div class="col-sm-12 col-md-3"> </div>
                </div>
                <% } %>
                <% if (DataType === 'String') { %>
                <div class="related-input-<%- Number%> row d-none">
                    <div class="col-sm-12 col-md-6">
                        <p class="form-control-static">
                            <%= _.unescape(QuestionText)%>
                        </p>
                    </div>
                    <div class="col-sm-12 col-md-6">
                        <input type="text" name="<%-QuestionCode%>"
                               class="text-questions full-width required-<%=IsRequired%>">
                    </div>
                </div>
                <% } else if (DataType === 'LongText') { %>
                <div class="related-input-<%- Number%> row d-none">
                    <div class="col-sm-12 col-md-6">
                        <p class="form-control-static">
                            <%= _.unescape(QuestionText)%>
                        </p>
                    </div>
                    <div class="col-sm-10 col-md-6">
                        <textarea name="<%-QuestionCode%>" class="text-questions full-width
                        required-<%=IsRequired%>"></textarea>
                    </div>
                </div>
                <% } else if (IsMainQuestion === false && DataType === 'Boolean') { %>
                <div class="related-input-<%- Number%> row d-none">
                    <div class="col-sm-12 col-md-9">
                        <p class="form-control-static">
                            <%= _.unescape(QuestionText)%>
                        </p>
                    </div>
                    <div class="twin-radio-group col-sm-12 col-md-3">
                        <div class="btn-group btn-toggle">
                            <button type="button" class="btn btn-lg btn-white btn-check" data-value="Y">Yes</button>
                            <button type="button" class="btn btn-lg btn-white btn-check" data-value="N">No</button>
                        </div>
                        <input type="hidden" class="twin-radio-value required-<%=IsRequired%>"
                               name="<%-QuestionCode%>">
                    </div>
                </div>
                <% } else { %>
                <div class="row">
                    <div class="col-sm-12 col-md-9">
                        <p class="form-control-static">
                            <%= _.unescape(QuestionText)%>
                        </p>
                    </div>
                    <div class="twin-radio-group col-sm-12 col-md-3" data-number="<%=Number%>">
                        <div class="btn-group btn-toggle">
                            <button type="button" class="btn btn-lg btn-white btn-check" data-value="Y">Yes</button>
                            <button type="button" class="btn btn-lg btn-white btn-check" data-value="N">No</button>
                        </div>
                        <input type="hidden" class="twin-radio-value required-<%=IsRequired%>"
                               name="<%-QuestionCode%>">
                    </div>
                </div>
            <% } %>
            </div>

<div class="form-group">
                <div class="row">
                    <div class="col-sm-12 col-md-9">
                        <label class="control-label">
                            <span class="text-pink">*</span> Question <%- sequenceNo%>
                        </label>
                    </div>
                    <div class="col-sm-12 col-md-3"> </div>
                </div>
                <div class="row">
                    <div class="col-sm-12 col-md-9">
                        <p class="form-control-static">
                            <%= _.unescape(questionText)%>
                        </p>
                    </div>
                    <% var possibleAnswer = possibleAnswers[0];
                    if (possibleAnswer.answerType === 'Radio' || possibleAnswer.answerType === 0) { %>
                    <div class="twin-radio-group col-sm-12 col-md-3">
                        <div class="btn-group btn-toggle">
                            <%_.each(possibleAnswers, function(a, i) {
                            var kclass = '';
                            if (possibleAnswer.isKnockOut) {
                                kclass = ' is-knockout';
                            }%>
                                <button type="button" name="questions-button" class="btn btn-lg btn-white btn-check" data-value="<%-a.id%>"><%-a.answerText%></button>
                                <input type="hidden" class="btn-check-error-message<%-kclass%>" value="<%-a.errorMessage%>">
                            <% }) %>
                        </div>
                        <input type="hidden" class="twin-radio-value" name="question-id-<%-questionId%>">
                    </div>
                    <% } else if (possibleAnswer.answerType === 'Checkbox' || possibleAnswer.answerType === 1) { %>
                    <div class="col-sm-12 col-md-6">
                        <input type="checkbox" name="question-id-<%-questionId%>" class="required-<%=possibleAnswer.isKnockOut%>">
                    </div>
                    <% } else if (possibleAnswer.answerType === 'FreeText' || possibleAnswer.answerType === 2) { %>
                    <div class="col-sm-12 col-md-6">
                        <input type="text" name="question-id-<%-questionId%>"
                               class="text-questions full-width required-<%=possibleAnswer.isKnockOut%>">
                    </div>
                    <% } %>
                </div>
            </div>

This coverage is not required to comply with federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.

I understand that by applying for coverage, I am agreeing to the items under Authorization above.*

I understand that by applying for coverage, I am agreeing to the items under Billing Authorization above.*

I agree and understand that I will receive my policy and/or certificate of issuance and other correspondence electronically.*

You're almost done,

All you need to do now is electronically sign your application and you're done! Type your name below to electronically sign your application: *

Please re-type your name below to electronically sign your application:

* required

eSignature and Submission

It is important that you carefully read and fully understand the following.

This is the information that we will include on your application to pay your first month’s premium directly to your insurance carrier.

Are you rewriting an existing National General Short Term Medical customer on a new National General Short Term Medical plan? This applies to National General Rewrites only.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The Loomis Company or its designated administrator in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that The Loomis Company or its designated administrator may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.

If applicable, premium will be debited immediately following receipt of the form.

Billing Authorization The accountholder of the bank account or credit card provided during this enrollment process authorizes and requests the Insurer to initiate automatic electronic payments against such indicated bank account or credit card for the payment of premiums and other indicated monthly dues included in the plan(s) being purchased during this enrollment process. Accountholder agrees that the electronic payment authorization for such automatic payments may be terminated by providing written notice to the Insurer.

Billing Info

we are submitting your application

<div class="form-group row">
                <label for="id_payment_method" class="col-md-4 col-form-label">Method of
                    Payment</label>

<div class="col-md-8">
                    <select id="id_payment_method" name="payment_method" class="form-control">
                        <option value="">Select a Payment Method</option>
                        <option value="1"
                        <%= payment_method == 1 ? 'selected' : void 0 %>>Credit Card</option>
                        <option value="2"
                        <%= payment_method == 2 ? 'selected' : void 0 %>>ACH</option>
                    </select>
                </div>
            </div>
            <div class="form-group row d-none">
                <label for="id_premium_mode-mode" class="col-md-4 col-form-label">Premium
                    Mode</label>

<div class="col-md-8">
                    <select id="id_premium_mode" name="premium_mode" class="form-control">
                        <option value="1" selected>Monthly</option>
                        <option value="2">Quarterly</option>
                        <option value="3">Annually</option>
                    </select>
                </div>
            </div>
            <div class="billing-credit-card">
                <div class="form-group row">
                    <label for="id_cc_name" class="col-md-4 col-form-label">Cardholder Name</label>

<div class="col-md-8">
                        <select id="id_cc_type" name="cc_type" class="form-control ihc-required">
                            <option value="">Select</option>
                            <option value="1">MasterCard</option>
                            <option value="2">Visa</option>
                            <option value="4">Discover</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_cc_number" class="col-md-4 col-form-label">Card
                        Number</label>

<div class="col-md-8">
                        <input id="id_cc_number" name="cc_number" type="text"
                               maxlength="17" class="form-control required" value="">
                    </div>
                </div>
                <div class="ng-only form-group row">
                    <label for="id_cc_cvv" class="col-md-4 col-form-label">Security Code (cvv) <a
                            href="#billing-cvv-help" data-toggle="collapse" tabindex="-1"><i class="fa fa-question-circle-o"
                                                                               aria-hidden="true"></i></a></label>

<div class="form-group row">
                    <label for="id_cc_exp_date" class="col-md-4 col-form-label">Expiration
                        Date</label>

<div class="col-md-3">
                        <select id="id_cc_exp_date" name="cc_exp_month" class="form-control required">
                            <option value="1">01</option>
                            <option value="2">02</option>
                            <option value="3">03</option>
                            <option value="4">04</option>
                            <option value="5">05</option>
                            <option value="6">06</option>
                            <option value="7">07</option>
                            <option value="8">08</option>
                            <option value="9">09</option>
                            <option value="10">10</option>
                            <option value="11">11</option>
                            <option value="12">12</option>
                        </select>
                    </div>
                    <div class="col-md-3">
                        <% var year = (new Date()).getFullYear();%>
                        <select name="cc_exp_year" class="form-control required">
                            <% _.each([0,1,2,3,4,5,6], function(y) { %>
                            <option value="<%=y + year%>"><%=y + year%></option>
                            <% }); %>
                        </select>
                    </div>
                </div>
            </div>
            <div class="billing-bank-draft">
                <div class="form-group row">
                    <label for="id_bd_name" class="col-md-4 col-form-label">Name on Check</label>

<div class="col-md-8">
                        <input id="id_bd_bank_name" name="bd_bank_name" type="text" maxlength="100"
                               class="form-control required" value="<%-bank_name%>">
                    </div>
                </div>
                <div class="row justify-content-end">
                    <div class="col-sm-12 col-md-8">
                        <div class="mt-2 mb-3">
                            <img src="/static/healthcare/images/check-diagram.jpg" class="img-check" alt="">
                        </div>
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_bd_type" class="col-md-4 col-form-label">Account Type</label>

<div class="col-md-8">
                        <select id="id_bd_type" name="bd_type" class="form-control required">
                            <option value="0">Checking</option>
                            <option value="1">Savings</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_bd_routing_number" class="col-md-4 col-form-label">Routing
                        Number</label>

<div class="col-md-8">
                        <input id="id_bd_routing_number" name="bd_routing_number" type="text" pattern="\d{9}"
                               maxlength="9"
                               class="form-control required" value="<%-bank_routing_number%>">
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_bd_account_number" class="col-md-4 col-form-label">Account
                        Number</label>

<div class="col-md-8">
                        <input id="id_bd_account_number" name="bd_account_number" type="text" pattern="\d{0,17}"
                               maxlength="20"
                               class="form-control required" value="<%-bank_account_number%>">
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-md-4 col-form-label">Relationship to Proposed Insured</label>

<div class="col-md-8">
                        <input name="bd_relation_to_applicant" value="<%- relation_to_applicant %>" type="text"
                               class="form-control ihc-required" maxlength="30">
                    </div>
                </div>
            </div>

<div class="card plan-card mb-4" data-plan-id="<%=plan_id_standard_component%>" data-exchange="<%-exchange%>">
    <h5 class="card-header selected-plan-message"><img src="/static/healthcare/images/favorite_24.png"> You have selected this plan</h5>
    <div class="card-body">
        <div class="plan-title row">
            <div class="col-sm-12 col-lg-9">
                <h4><%=plan_marketing_name.replace(/\?/gi, '')%> - <%-plan_type%></h4>
                <div><%=issuer_name%></div>
                <%if (exchange === 'off') { %>
                <p class="text-danger agent-only-view"><small>This is an off-exchange-only plan</small></p>
                <% } %>
            </div>
            <div class="col-sm-12 col-lg-3">
                <a data-plan-id="<%=plan_id_standard_component%>"
                   data-plan-cost="<%=monthly_cost.toString().replace(/\$/gi, '')%>"
                   class="enroll-plan btn btn-lg btn-primary" href="#" role="button">Apply Now</a>
            </div>
        </div>
        <%var totalApplicants = 0,
            subsidy = 0,
            monthlyCostDisplay;
        if (typeof extraData !== 'undefined' && extraData) {
            totalApplicants = extraData.totalApplicants;
            subsidy = extraData.subsidy;
        } else if (navController.shopper.members) {
            totalApplicants = navController.getMembers().availableAges.length;
            subsidyStore = navController.shopperStorage['subsidy'];
            if (typeof subsidyStore !== 'undefined' && subsidyStore) {
                subsidy = subsidyStore.subsidy;
            } else {
                subsidy = navController.shopper.subsidy;
            }
        }
        if (exchange === 'on') {
            var monthlyCostSubsidy= Math.max(0, monthly_cost - subsidy);
            if (monthlyCostSubsidy > 0) {
                monthlyCostSubsidy = monthlyCostSubsidy.toFixed(2);
            }
            monthlyCostDisplay = monthlyCostSubsidy.toString();
        } else {
            var monthlyCost= Math.max(0, monthly_cost);
            monthlyCost = monthlyCost.toFixed(2);
            monthlyCostDisplay = monthlyCost.toString();
        }
        var index = monthlyCostDisplay.indexOf('.');%>
        <div class="plan-cost row align-items-end">
            <div class="col-sm-12 col-md-4">
                <div>Monthly Cost <a tabindex="-1" role="button"
                        data-content="amount you pay the insurance company each month. This does not go towards your deductible or out of pocket maximum."
                        class="popover-help-text" data-toggle="popover"
                        data-container="body" data-trigger="focus" data-placement="top"><small><i class="fa fa-question-circle-o"></i></small></a></div>
                <h2 class="monthly-cost no-wrap-text">
                    <% if (monthlyCostDisplay === '0') { %>
                    $0
                    <% } else { %>
                    $<%=monthlyCostDisplay.substring(0, index)%><sup><span><%=monthlyCostDisplay.substring(index)%></span></sup>
                    <% } %>
                </h2>
                <div class="fade-text">per month</div>
            </div>
            <div class="col-sm-12 col-md-4">
                <div>Deductible <a tabindex="-1" role="button"
                        data-content="amount you owe for major services like hospitalizations, maternity, MRIs, and surgery before your health plan begins to pay."
                        class="popover-help-text" data-toggle="popover"
                        data-container="body" data-trigger="focus" data-placement="top"><small><i class="fa fa-question-circle-o"></i></small></a></div>
                <h2 class="other-cost"><%-medical_deductible_individual_standard%></h2>
                <%if (totalApplicants > 2) { %>
                <div class="other-cost-group-2 fade-text">per family</div>
                <% } else { %>
                <div class="other-cost-group-1 fade-text">per person</div>
                <% } %>
            </div>
            <div class="col-sm-12 col-md-4">
                <div>Max Out of Pocket <a tabindex="-1" role="button"
                        data-content="max amount you'll pay during a calendar year. Includes deductible, coinsurance and all copays."
                        class="popover-help-text" data-toggle="popover"
                        data-container="body" data-trigger="focus" data-placement="top"><small><i class="fa fa-question-circle-o"></i></small></a></div>
                <h2 class="other-cost"><%-medical_maximum_out_of_pocket_individual_standard%></h2>
                <%if (totalApplicants > 2) { %>
                <div class="other-cost-group-2 fade-text">per family</div>
                <% } else { %>
                <div class="other-cost-group-1 fade-text">per person</div>
                <% } %>
            </div>
        </div>
        <% if (exchange == 'on') { %>
        <div class="subsidy-original-cost row mb-2">
            <div class="col-12 text-muted">
                <i>monthly cost before premium tax credit: <span class="original-cost">$<%=monthly_cost.toString().replace(/\$/gi, '')%></span></i>
            </div>
        </div>
        <% } %>
        <div class="visit-cost row" data-plan-id="<%=plan_id_standard_component%>">
            <div class="col-sm-12 col-md-6">
                <div class="fade-text">DOCTOR VISIT COPAY <a tabindex="-1" role="button" data-content="Amount you pay per doctor visit"
                        class="popover-help-text" data-toggle="popover"
                        data-container="body" data-trigger="focus" data-placement="top"><small><i class="fa fa-question-circle-o"></i></small></a></div>
                <div>
                    <span class="fade-text">Primary:</span>
                    <span class="pcp-cost cost"><%-primary_care_physician_standard%></span>
                </div>
                <div>
                    <span class="fade-text">Specialist:</span>
                    <span class="cost"><%-specialist_standard%></span>
                </div>
                <div><a class="find-doctor" href="<%-network_url%>" target="_blank"><small><i class="fa fa-search"></i></small> Find your doctor</a></div>
            </div>
            <div class="col-sm-12 col-md-6">
                <div class="fade-text">PRESCRIPTION COPAY <a tabindex="-1" role="button" data-content="Amount you pay for a 30 day supply of prescription drugs at a pharmacy"
                        class="popover-help-text" data-toggle="popover"
                        data-container="body" data-trigger="focus" data-placement="top"><small><i class="fa fa-question-circle-o"></i></small></a></div>
                <div>
                    <span class="fade-text">Generic:</span>
                    <span class="cost"><%-generic_drugs_standard%></span>
                </div>
                <div>
                    <span class="fade-text">Brand:</span>
                    <span class="cost"><%-preferred_brand_drugs_standard%></span>
                </div>
            </div>
        </div>
        <div class="medical-container d-none">
            <img src="/static/healthcare/images/medical.png" alt="">
            <span class="medical-names" data-plan-id="<%-plan_id_standard_component%>"></span>
        </div>
    </div>
    <div class="plan-footer card-footer">
        <div class="row">
            <div class="col-sm-12 col-lg-4">
                <div class="plan-metal-circle plan-metal-circle-<%-metal_level.toLowerCase().replace(' ','')%>"></div>
                <div class="plan-metal-text"><%-metal_level%></div>
            </div>
            <div class="plan-actions col-sm-12 col-lg-8 text-right">
                <a href="<%- summary_of_benefits_url%>" class="detail-url" target="_blank"><small><i class="fa fa-reorder hidden-lg-down"></i></small> details</a>
                <span class="hidden-lg-down"></span>
                <a class="plans-compare-add" data-plan-id="<%-plan_id_standard_component%>" href="#"><span class="hidden-xl-up"> | </span><small><i class="plan-compare-add fa fa-plus hidden-lg-down"></i></small> compare</a>
                <span class="hidden-lg-down"></span>
                <a class="plans-email-add" data-plan-id="<%-plan_id_standard_component%>" href="#"><span class="hidden-xl-up"> | </span><small><i class="fa fa-plus hidden-lg-down"></i></small> email</a>
            </div>
        </div>
    </div>
</div>

Please fill out all information

Thank you for completing your application!

We've emailed you a confirmation email for your records. Our agents will process your application and within 5-15 days your plan information & premium bill will be mailed to you by the insurance carrier, or in some cases, you will be able to pay your bill online.

Click here to review your application. If additional information is required, an agent or the insurance carrier may reach out to you to complete your application.

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<tbody>
            <tr>
                <td>
                    <span class="text-info"><%- date_updated %></span>
                    <% if (typeof processing_status_name != 'undefined' && processing_status_name) { %>
                    <span class="text-muted">
                    <% if (processing_status_name == 'processed' || processing_status_name == 'processing') { %>
                        (application submitted)
                        <% } else if (processing_status_name == 'canceled') { %>
                        (application canceled)
                        <% } else if (processing_status_name == 'pending') { %>
                        (currently being processed)
                        <% } else if (processing_status_name == 'unfinished') { %>
                        (you have not submitted this application)
                        <% } else if (processing_status_name == 'waiting_payment') { %>
                        (waiting for payment)
                        <% } else if (processing_status_name == 'processed') { %>
                        (application completed)
                        <% } %>
                    </span>
                    <% } %>
                </td>
                <td>
                    <div class="text-info text-right">
                        <%if (parseInt(processing_status) < 2) { %>
                        <a href="<%- editLink%>"><small><span class="fa fa-pencil"></span></small> edit</a>
                        <% } else { %>
                        <img class="b-lazy" src="/static/healthcare/images/ph.png" data-src="/static/healthcare/images/accept_24.png" alt="">
                        <% } %>
                    </div>
                </td>
            </tr>
            <tr>
                <td class="plan-detail">
                    <% if (typeof plan_name != 'undefined' && plan_name) { %>
                        <div><%- plan_name %></div>
                    <% } %>
                    <% if (typeof plan_cost != 'undefined' && plan_cost && plan_cost > 0){ %>
                        <div>
                            <% var monthly_cost = parseInt(plan_cost) %>
                            <% if (selectionsObj.subsidy && selectionsObj.subsidy !== '') { %>
                            $<%- Math.max(0, Math.ceil(monthly_cost - parseInt(selectionsObj.subsidy)))%> per month
                        <span class="text-muted"><small>(monthly cost before premium tax credit: $<%- monthly_cost %>)</small></span>
                            <% } else { %>
                            $<%-monthly_cost %>
                            <% } %>
                        </div>
                    <% } %>
                    <% if (typeof ages != 'undefined' && ages) { %>
                        Ages of applicants: <%- ages %>
                    <% } %>
                    <% if (typeof num_applicants != 'undefined' && num_applicants) { %>
                        Number of applicants: <%- num_applicants %>
                    <% } %>
                    <% if (typeof date_finalized != 'undefined' && date_finalized) { %>
                        <div class="text-info">
                            processed on <%- date_finalized %>
                        </div>
                    <% } %>
                </td>
                <td>
                </td>
            </tr></tbody>

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