 Application Detail |
| Application Name | Individual Application | Application Reference Number | A-00328602 |
| Application # | A-00328602 | Internal Status | Manually Cancelled |
| Opportunity | External Status | Cancelled | |
| Exchange Application # | Type | Individual Under 65 Quote | |
| Plan Selected | Bronze HMO 6500 | Agency Member No |
Subscriber Information
| Date of Birth | 7/19/1953 | Requested Coverage Effective Date | 1/1/2018 |
| Requesting Dependent Coverage | No | ||
| Tobacco Use | No |
Applicant Information
| Salutation | Mrs. | First Name | Janet |
| Middle Name | J | Last Name | Strausser |
| Suffix | Gender | Female | |
| Social Security Number | XXX-XX-7728 |
Address Information
| Physical Street | 412 Lily Bay Road | Mailing Street | |
| Physical City/Town | Greenville | Mailing City / Town | |
| Physical State | ME | Mailing State | |
| Physical ZipCode | 04441 | Mailing ZIP Code |
Phone And Email
| HomePhone | 5704043700 | Mobile Phone | |
| Work Phone | dkstrausser@gmail.com.sit | ||
| Additional Email |
Broker Information
| Broker | BrokerNPN | ||
| Agent ID / Vendor ID |
PCP Information
| PCP ID# | 714864 | PCP Name | |
| PCP City/Town | Greenville | PCP Last Name | Peck |
| Current Patient | Yes |
Payment Description
| Payment Transaction id | |||
| Created By | Member Community Site Guest User, 12/4/2017 11:24 AM | Last Modified By | Ashutosh Tiwari, 12/17/2021 1:36 PM |
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