Clone of ICHRA/CHOICE Referral Form for ATMA PMF

1

Your Name (Agent)* This field is required.

First Name

Last Name

2

Your Email (Agent)* This field is required.

jdoe@voluntarypartners.com

3

Your Phone Number (Agent)* This field is required.

Area Code

Phone Number

4

Referred COMPANY Name:* This field is required.

5

Decision Maker's Name* This field is required.

First Name

Last Name

6

Decision Maker's Phone Number* This field is required.

Area Code

Phone Number

7

Decision Maker's Email* This field is required.

example@example.com

8

How many employees do they have working 30 hours or more per week? * This field is required.

9

What is the situs state of this group?* This field is required.

10

GREAT NEWS {yourName}!

Here's what's in it for you.

Mike is a true pro that has been in your shoes in the VB space. He is also one of the top producing BROKER PARTNERS with VIP that is here to benefit your client while protecting your interest in VB! No looking over your shoulder!

11

What is the biggest priority for them when offering a health plan to the employees? And do you have any special notes or requests for Mike?

12

Do they currently offer a GROUP Health Insurance Plan?* This field is required.

Yes

No

13

How many employees are on this GROUP plan? * This field is required.

14

On a scale of 1-10…How close is this company to dropping the Group Health plan because it is deemed “Unaffordable” to the Company?* This field is required.

15

How much emphasis does this company place on offering the best possible health benefits to their employees?* This field is required.

16

Upload your complete Census here if you have one.

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17

Choose your Executive Partner Team

Team BAD AZ & CO - Denise Forconi

TEAM The Rhythm - Alfred and Karen Rietkerk

Team Trailblazers - Zach Milwood and Rick McKinney

Team Powerhouse - Susan Svarda

National Broker Team - Alex Sell