InsuranceGroup || Applications Option 1

Client's first name

Client's last name

Submitted

Effective Date

Seller

Company

	Name	Company	Plan	Submitted	Seller	Effective Date	Actions
	${a.firstName} ${a.lastName}	${a.name}	${a.company}	${a.plan}	${moment(a.created).format('MM/DD/YYYY h:mm a')}	${a.seller}	${a.effectiveDate}

Page: ${page} of ${pages}

Member ID

Required

# of members

First Name

Required

Last Name

DOB

Please enter a valid date. MM/DD/YYYY

Required

Phone number

Company

Plan

State

Effective Date

Zip Code

Previous Plan

Plan Change Date

Notes

${moment(note.date).format('MM/DD/YYYY h:mm a')} - ${note.text}

${application.notes}

File

${f}

Date Editing