ACA Referral Form

    • Insured Information
    • Additional Household Members
    • Income Information
    • Referring Agent Information


    Instructions

    Fill out the form below as completely as possible.
    An Empower agent will then contact your client and finish the application.
    We recommend keeping a list of your referred clients and staying in touch with them.
    Don't forget to ask your client for referrals.
    This is a secure form, and will be sent internally to an authorized ACA agent at Empower Brokerage


    Insured Information
    Best Time to Contact
    First Name (required)
    Last Name (required)
    Street Address
    Suite #
    City
    State
    Zip
    Phone
    Email
    Gender
    Date of Birth
    Social Security Number
    Smoker?
    U.S. Citizen?
    Additional Household Members

    Additional Member #1

    Member 1 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #2

    Member 2 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #3

    Member 3 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #4

    Member 4 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #5

    Member 5 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #6

    Member 6 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #7

    Member 7 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #8

    Member 8 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #9

    Member 9 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?

    Additional Member #10

    Member 10 Name
    Date of Birth
    Social Security Number
    Gender
    Relationship
    Smoker?
    U.S. Citizen?
    Needs Coverage?
    Income Information

    List all sources and amounts of income, including the household member earning it.

    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Member Name
    Income Source
    Amount Yearly
    Referring Agent Information
    Sales Agent Name
    Agent Email
    Agent Phone
    National Producer #
    Notes

    Please verify that all the information you have entered is correct.
    Then click the Submit button to send us your referral

     

    AGREEMENT: By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. I agree that I am the current authorized user of the phone number and e-mail address submitted. I expressly consent to opt in to receive e-mails and text messages from Empower Brokerage about health insurance, life insurance, Medicare Supplements, Medicare services and other options. Empower Brokerage is an independent insurance agency and is not affiliated with the federal Medicare program. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign by Empower Brokerage, and I will receive text messages and e-mails as part of the ongoing Empower Brokerage marketing campaign. By clicking and submitting this form, I am authorizing Empower Brokerage to call, e-mail, or text me at the phone number and email address I provided (even if that phone number is on any Do Not Call Registry or is a mobile number). I am consenting to calls with Empower Brokerage being recorded and monitored.
    Standard text and data rates may apply. You can opt out of receiving text messages from Empower Brokerage at any time by replying to an Empower Brokerage text message with “unsubscribe”, “stop”, “end”, “no”, or “opt out”. If you want to opt out of receiving future e-mails from Empower Brokerage, then you can do so at any time. Please click the “unsubscribe” button in our e-mail. Empower Brokerage values your privacy and will not share your personal information with any other business or persons.



    Click Here to reset the form and enter another referral