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Landing Page Part B
1
User ID
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2
Health Insurance Information
*
This field is required.
Primary Insurance Company
Plan Name
Policy ID#
Group Number
Date of Birth
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3
Relationship to the Primary Subscriber
*
This field is required.
Doyou get Insurance Coverage from someone other than yourself?
Self
Spouse
Child
Other
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4
Primary Subscriber
Please enter primary subscriber's information
First Name
Last Name
Date of Birth
Email (if different than above)
Employer
Job title
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5
Primary Subscriber Employer
Employer
Job title
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6
Do you have secondary insurance?
Yes
No
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7
Secondary Health Insurance Information
Primary Insurance Company
Plan Name
Policy ID#
Group #
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8
Relationship to the Secondary Insurance Subscriber
*
This field is required.
Do you get Insurance Coverage from someone other than yourself?
Self
Spouse
Child
Other
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9
Secondary Insurance Subscriber
First Name
Last Name
Date of Birth
Email (if different than above)
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