 Application Detail |
| Application Name | Individual Application2021-01-20 18:05:29 | Application Reference Number | A-00601076 |
| Application # | A-00601076 | Internal Status | Enrolled |
| Opportunity | External Status | Enrolled | |
| Exchange Application # | Type | Individual Quote SEP | |
| Plan Selected | HMO Bronze 8550 | Agency Member No |
Subscriber Information
| Date of Birth | 1/27/1983 | Requested Coverage Effective Date | 2/1/2021 |
| Requesting Dependent Coverage | No | ||
| Tobacco Use | No |
Applicant Information
| Salutation | First Name | Oliver | |
| Middle Name | Last Name | Merrill | |
| Suffix | Gender | Male | |
| Social Security Number | XXX-XX-2076 |
Address Information
| Physical Street | 33 Evergreen Terrace | Mailing Street | 33 Evergreen Terrace |
| Physical City/Town | SEBEC | Mailing City / Town | SEBEC |
| Physical State | ME | Mailing State | ME |
| Physical ZipCode | 04481 | Mailing ZIP Code | 04481 |
Phone And Email
| HomePhone | 7248405164 | Mobile Phone | |
| Work Phone | amerrill@livinginnovations.com.sit | ||
| Additional Email |
Broker Information
| Broker | Take Command Health | BrokerNPN | 674753 |
| Agent ID / Vendor ID | 674753 |
PCP Information
| PCP ID# | 12091107 | PCP Name | |
| PCP City/Town | Dover Foxcroft | PCP Last Name | Chandler |
| Current Patient | No |
Payment Description
| Payment Transaction id | 1731733 | ||
| Created By | Member Community Site Guest User, 1/20/2021 1:05 PM | Last Modified By | Jasmin Jena, 1/13/2022 9:32 AM |
| |
Notes & Attachments |
| Action | Type | Title | Last Modified | Created By |
|---|---|---|---|---|
| Edit | View | Del | Attachment | 2021-ichra-employee-notice-mosaic-Merrill.pdf | 1/20/2021 1:07 PM | Member Community Site Guest User |
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