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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 class="card plan-card mb-4">
    <div class="card-body">
        <div class="plan-title row">
            <div class="col-sm-12 col-md-9">
                <h4>National General <%-DisplayName%></h4>
            </div>
            <div class="col-sm-12 col-md-3">
                <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="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(Rate).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"><%-CoinsuranceMaximumOOP.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.toDollar()%></small></div>
            <div class="col-6 text-right">
            <% } else { %>
            <div class="col-12 text-right">
            <% } %>
            <a href="<%-ProviderLink%>/<%-PathToBrochure%>" class="detail-url" target="_blank"><i class="fa fa-reorder"></i> details</a>
            </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>
            <div class="d-none">
                <input name="is_guest_user_create" type="text" value="0">
                <input name="email" type="text" value="">
                <input name="submission_log" type="text" value="">
            </div>

Please fill out your information

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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">Person <span class="counter"><%= i + 1 %></span></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 curYear = (new Date()).getFullYear(), year, month, day;
                            if (n.birth_date) {
                                year = n.birth_date.slice(0, 4);
                                month = n.birth_date.slice(5, 7);
                                day = n.birth_date.slice(8, 10);
                                if (month.indexOf('0') === 0) {
                                    month = month.slice(1, 2);
                                }
                                if (day.indexOf('0') === 0) {
                                    day = day.slice(1, 2);
                            }}%>
                            <label>Birth Date</label>
                            <div class="birth-date-text"><i><%- month + '/' + day + '/' + year %></i></div>
                            <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 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="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>Marital status</label>
                            <select name="marital_status_0" class="form-control mb-2 mr-sm-2 mb-sm-0" required>
                                <option value="">Choose...</option>
                                <option value="1"<%= n.marital_status == 1 ? 'selected' : void 0 %>>Single</option>
                                <option value="2"<%= n.marital_status == 2 ? 'selected' : void 0 %>>Married</option>
                                <option value="3"<%= n.marital_status == 3 ? 'selected' : void 0 %>>Domestic Partner</option>
                                <option value="4"<%= n.marital_status == 4 ? 'selected' : void 0 %>>Civil Union Partner</option>
                            </select>
                        </div>
                        <div class="form-group col-sm-12 col-md-6">
                            <label>Relationship</label>
                            <select name="relationship_0" class="d-none" required>
                                <option value="">Choose...</option>
                                <option value="0"<%= n.relationship == 0 ? 'selected' : void 0 %>>Applicant</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>
                            <i><span class="relationship-text">
                                <% if (n.relationship === 0) { %>
                                Applicant
                                <% } else if (n.relationship === 1) { %>
                                Spouse
                                <% } else { %>
                                Dependent
                                <% } %>
                            </span></i>
                            </div>
                        </div>
                    </div>
                    <div class="row">
                        <div class="form-group col">
                            <label>Social security number
                            <input name="ssn_0" type="text" class="form-control" value="<%- n.ssn %>"></label>
                        </div>
                    </div>
                    <div class="form-smoker-checkbox row">
                        <div class="form-check col">
                            <label class="form-check-label"><input name="smoker_0" type="checkbox" class="form-check-input" value="1" <%= n.smoker == true ? 'checked' : void 0 %> disabled> Has regularly used tobacco within the past six months
                             </label>
                        </div>
                    </div>
                </div>
            </div>
            <% }); %>

You did not enter information for the applicant

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">Person <span class="counter"><%= i + 1 %></span></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 curYear = (new Date()).getFullYear(), year, month, day;
                            if (n.birth_date) {
                                year = n.birth_date.slice(0, 4);
                                month = n.birth_date.slice(5, 7);
                                day = n.birth_date.slice(8, 10);
                                if (month.indexOf('0') === 0) {
                                    month = month.slice(1, 2);
                                }
                                if (day.indexOf('0') === 0) {
                                    day = day.slice(1, 2);
                            }}%>
                            <label>Birth Date</label>
                            <div class="birth-date-text"><i><%- month + '/' + day + '/' + year %></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>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>
                            <i><span class="relationship-text">
                                <% if (n.relationship === 0) { %>
                                Primary
                                <% } else if (n.relationship === 1) { %>
                                Spouse
                                <% } else { %>
                                Dependent
                                <% } %>
                            </span></i>
                            </div>
                        </div>
                        <div class="form-group col">
                            <label>Social Security Number</label>
                            <input name="ssn_0" type="text" class="form-control" value="<%- n.ssn %>">
                        </div>
                    </div>
                    <div class="form-smoker-checkbox row">
                        <div class="form-check col">
                            <label class="form-check-label"><input name="smoker_0" type="checkbox" class="form-check-input" value="1" <%= n.smoker == true ? 'checked' : void 0 %> disabled> Has regularly used tobacco within the past six months
                             </label>
                        </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.

<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>
                    <% if (PossibleAnswers[0].AnswerType === 'Radio') { %>
                    <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 (PossibleAnswers[0].IsKnockout) {
                                kclass = ' is-knockout';
                            }%>
                                <button type="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 (PossibleAnswers[0].AnswerType === 'Checkbox') { %>
                    <div class="col-sm-12 col-md-6">
                        <input type="checkbox" name="question-id-<%-QuestionId%>" class="required-<%=IsKnockout%>">
                    </div>
                    <% } else if (PossibleAnswers[0].AnswerType === 'FreeText') { %>
                    <div class="col-sm-12 col-md-6">
                        <input type="text" name="question-id-<%-QuestionId%>"
                               class="text-questions full-width required-<%=IsKnockout%>">
                    </div>
                    <% } %>
                </div>
            </div>

Short Term Medical

ACCEPTANCE AND ACKNOWLEDGEMENT:

I hereby apply for the coverage selected on this application form. I understand that the coverage shall not become effective until this application is accepted by the insurer and the initial premium is paid. I read this application carefully and represent that the information I provided is true, correct and complete. I understand that the insurer relied on my statements and my answers to the medical history questions and it is the basis for determining the issuance or denial of coverage. I understand that any misstatement or omission may result in the denial of benefits and/or the termination of coverage.

I agree and understand that coverage will not become effective for any applicant whose medical history changes prior to that person’s Effective Date such that the applicant’s answer would be “yes” to any of the medical history questions in this application and agree to immediately notify the insurer of any such changes. If such person is the Applicant, I understand that coverage is automatically declined for all persons applying on this application.

I understand that health insurance benefits are excluded for pre-existing conditions and this coverage will not pay benefits for a disease or physical condition that I or another applicant may now have or have had within 5 years of the application for coverage.

I understand that the producer who solicited this application and upon whose explanation of the benefits, limitations or exclusions I relied on was retained by me as my agent and is an independent contractor who has no right to alter the application, bind or approve coverage or alter any of the terms or conditions of the policy.

I understand that cancellation of this coverage within the 10 day right to return the policy period will result in a refund of premiums only. Any administrative fees or other fees that may apply will not be refunded.

I understand that this coverage for which I am applying is not Minimum Essential Coverage as defined by the Affordable Care Act of 2010 (ACA). Even if I have this coverage, I still may be subject to the federal tax assessed against individuals without Minimum Essential Coverage.

AUTHORIZATION TO RELEASE INFORMATION: I authorize any health care provider, doctor, medical professional, medical facility, insurance company, pharmacy benefit manager, person or organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability of employment related information concerning the patient, excluding genetic information, to the insurer or its administrator.

You agree and consent the use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using this website; or in accessing or making any transactions regarding this application constitutes your signature, acceptance, and agreement as if actually signed by you in writing. Further, you agree no certification authority or other third party verification is necessary to the validity of your electronic signature; and the lack of such certification or third party verification will not in any way affect the enforceability of your signature or the resulting contract. You warrant that all the information you have provided is true, complete and accurate.

Please note:

Any electronic document bearing a user’s e-signature will be considered "in writing" and "wet-signed".
Any user e-signed document shall be deemed to be an “original” document when printed and used in the normal course of business.
Absent manifest error, the admissibility, validity, or use of any e-signed electronic document cannot be contested.

Short Term Medical

Fraud Warning:

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading may be guilty of insurance fraud and subject to criminal and/or civil penalty.

Applicant signature is required

Spouse signature is required

Applicants under the age of 18 must have a Parent/Guardian signature

Review and Acknowledge

Please verify that you accept and understand the terms and disclaimers below, and complete the electronic signature.

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:

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-5 col-form-label">Method of
                    Payment</label>

<div class="col-md-7">
                    <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-5 col-form-label">Premium
                    Mode</label>

<div class="col-md-7">
                    <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-5 col-form-label">Cardholder Name</label>

<div class="col-md-7">
                        <select id="id_cc_type" name="cc_type" class="form-control ihc-required">
                            <option value="">Select</option>
                            <option value="1"
                            <%= cc_type == 1 ? 'selected' : void 0 %>>MasterCard</option>
                            <option value="2"
                            <%= cc_type == 2 ? 'selected' : void 0 %>>Visa</option>
                            <option value="4"
                            <%= cc_type == 4 ? 'selected' : void 0 %>>Discover</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_cc_number_secure" class="col-md-5 col-form-label">Card
                        Number</label>

<div class="col-md-7">
                        <input id="id_cc_number_secure" name="cc_number_secure" type="text"
                               maxlength="17" class="form-control required" value="">
                    </div>
                </div>
                <div class="ng-only form-group row">
                    <label for="id_cc_cvv_secure" class="col-md-5 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="col-md-7">
                        <input id="id_cc_cvv_secure" name="cc_cvv_secure" type="text" maxlength="4"
                               class="form-control ng-required" value="<%-cc_cvv_secure%>" pattern="\d{0,4}">

<div class="form-group row">
                    <label for="id_cc_exp_date" class="col-md-5 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-5 col-form-label">Name on Check</label>

<div class="col-md-7">
                        <select id="id_bd_type" name="bd_type" class="form-control required">
                            <option value="1">Checking</option>
                            <option value="2">Savings</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_bd_routing_number" class="col-md-5 col-form-label">Routing
                        Number</label>

<div class="col-md-7">
                        <input id="id_bd_routing_number" name="bd_routing_number" type="text" pattern="\d{0,9}"
                               maxlength="9"
                               class="form-control required" value="<%-bd_routing_number%>">
                    </div>
                </div>
                <div class="form-group row">
                    <label for="id_bd_account_number" class="col-md-5 col-form-label">Account
                        Number</label>

<div class="col-md-7">
                        <input id="id_bd_account_number" name="bd_account_number" type="text" pattern="\d{0,17}"
                               maxlength="20"
                               class="form-control required" value="<%-bd_account_number%>">
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-md-5 col-form-label">Relationship to Proposed Insured</label>

<div class="col-md-7">
                        <input name="bd_relation_to_applicant" value="<%- bd_relation_to_applicant %>" type="text"
                               class="form-control ihc-required" maxlength="30">
                    </div>
                </div>
            </div>

<div class="row">
                <div class="col">
                    <div><%-Name%> <%- DisplayName%></div>
                </div>
                <div class="col">$<%- InsuranceRate%></div>
            </div>
            <% if (AssociationFee > 0) { %>
            <div class="row">
                <div class="col">Association Fee:</div>
                <div class="col">$<%- AssociationFee%></div>
            </div>
            <% } %>
            <div class="row">
                <div class="col">One-time Enrollment Fee:</div>
                <div class="col">$<%- EnrollmentFee%></div>
            </div>
            <div class="monthly-total row">
                <div class="col">Monthly Total:</div>
                <div class="col">$<%= (parseInt(parseFloat(Rate) + parseFloat(AssociationFee))).toFixed(2)%></div>
            </div>
            <div class="row">
                <div class="col">Initial Payment:</div>
                <div class="col">$<%- TotalRate%></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.

Thank you for choosing iHealthAgents!

Your Applications

Click here to start your healthcare application

<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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