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