arclight1stg, Author at ArcLight Insurance

Newborn Health Insurance Submission

Name

This field is for validation purposes and should be left unchanged.

Newborn Information

Full Name of Baby A(Required)

First Middle Last

Baby A Date of Birth(Required)

Baby A Birth Sex(Required)

Full Name of Baby B

First Middle Last

Baby B Date of Birth

Baby B Birth Sex

Delivery Hospital Information

Delivery Hospital Name(Required)

Delivery Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Intended Parent Information

Intended Parent 1 Name(Required)

First Last

Intended Parent 2 Name

First Last

Intended Parent Address(Required)

Please list your United States address.

Street Address Address Line 2 City State ZIP Code

Intended Parent Phone Number(Required)

Please list your United States phone number.

Intended Parent Email(Required)

Please provide a copy of proof of birth from the hospital and/or Birth Certificate.

Upload the document(s) below, or email us at submissions@arclightinsurance.com following your completion of this form. Note: Any documents are uploaded only to our secure server.

Drop files here or

Accepted file types: jpg, png, pdf, heic, Max. file size: 50 MB, Max. files: 2.

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Are you an agency or an individual?(Required)

Agency

Individual

Agency Name(Required)

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Signee Full Name(Required)

First Last

Please re-print your name, your "Electronic Signature" below:(Required)

Date(Required)

Please leave any additional comments or instructions here:

by arclight1stg

Newborn Health Insurance Search

Name

This field is for validation purposes and should be left unchanged.

Has the newborn been delivered yet?(Required)

Yes

Expected Delivery Date(Required)

Date of Birth(Required)

Name of Delivery Hospital(Required)

Address of Delivery Hospital(Required)

Street Address Address Line 2 City State ZIP Code

Name of Obstetrician(Required)

Please list if singleton or twins:

Intended Parent(s) Information

Intended Parent 1 Name(Required)

First Last

Intended Parent 1 Email(Required)

Intended Parent 1 Phone(Required)

Intended Parent Name (2)

First Last

Intended Parent 2 Email

Intended Parent 2 Phone

Intended Parent Address(Required)

Street Address Address Line 2 City State ZIP Code

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Are you an agency or an individual?(Required)

Agency

Individual

Agency Name(Required)

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Please review the following terms of agreement:(Required)

ArcLight Insurance Services, Inc. "ArcLight" shall provide the health insurance review services to the Client beginning on the Effective Date, subject to these Terms and Conditions (the "Agreement"):

1. ArcLight shall conduct a search on behalf of Client in an effort to locate one or more newborn-compatible health insurance policies offering coverage for non-resident individuals (the “Services”). The Services shall be limited to: 1) locating one or more compatible insurance policies, 2) determining if such policy(ies) are accepted at Client’s delivery hospital, and 3) if not accepted, identifying other nearby hospitals that do accept such policy(ies). ArcLight shall not be required to provide any service to the extent the performance of such service becomes impracticable and shall not be held liable for any delays due to a force majeure event or any event outside of ArcLight’s control.

2. A fee of $300 shall be due and payable by Client on the Effective Date for the Services of ArcLight and is non-refundable in all cases.

3. Client represents and warrants that all information provided to ArcLight is complete and accurate. Client shall provide authorization to ArcLight as needed for ArcLight to effectively provide the Services hereunder, including providing the necessary written or verbal authorizations to allow ArcLight to act on behalf of the Client in connection with the Services.

4. Client understands and acknowledges that the Services do NOT constitute the offering or provision of an insurance policy. Client specifically acknowledges and agrees that ArcLight only identifies and collects information related to potential insurance policies of Client. Neither ArcLight nor any of its affiliates or authorized delegees represent themselves as insurance providers or in any manner interfere with or participate in the insurance company-Client relationship. All insurance and delivery hospital decisions shall be made by Client and neither ArcLight, nor any of its affiliates or authorized delegees shall be held responsible for any insurance obtained, or the failure or inadequacy of any insurance coverage to be provided to Client. The selection of an insurance policy or delivery hospital is at the Client’s sole discretion, and is not based upon the credentialing or any recommendation by ArcLight or any of its affiliates or authorized delegees. ArcLight is not responsible for limitations on the effectiveness of the Services or their effect, or lack of effect, on the insurance policy or coverage of Client.

5. It is the express intention of the parties that ArcLight is an independent contractor and not an employee, agent, joint venturer or partner of Client.

6. Client acknowledges and agrees that ArcLight may subcontract with other persons or entities, including entities related to ArcLight by ownership or control, to perform any part or all of the Services required of ArcLight hereunder. Any such subcontracting by ArcLight shall not affect the rights and obligations of the parties hereunder.

7. For purposes of this Agreement, “Confidential Information” means any information, software, material, data or business, financial, operational, customer and other information disclosed to one party by the other, in each case solely to the extent such information is not generally known by or disclosed to the public. Confidential Information shall include, without limitation, the terms of this Agreement. The party receiving Confidential Information shall hold such Confidential Information in strict confidence and shall exercise the same degree of care it uses with respect to its own Confidential Information, and in no event less than a reasonable degree of care.

8. This Agreement contains the entire agreement of the parties and there are no other promises or conditions in any other agreement whether oral or written.

9. This Agreement shall be governed by and construed in accordance with the laws of the State of California.

10. EXCEPT AS EXPRESSLY SET FORTH IN THIS AGREEMENT, CLIENT ACKNOWLEDGES AND AGREES THE SERVICES PROVIDED AND MATERIALS PRODUCED UNDER THE TERMS OF THIS AGREEMENT ARE PROVIDED TO CLIENT “AS IS,” THAT IS, WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESS OR IMPLIED, AND IN PARTICULAR, DOES NOT MAKE ANY IMPLIED WARRANTY OF MERCHANTABILITY OF FITNESS OR FOR A PARTICULAR PURPOSE. ArcLight’s liability, including, but not limited to, any of Client’s claims of contributions and indemnification related to third party claims arising out of the Services rendered by ArcLight, and for any losses, injury, or damages to persons or properties or work performed arising out or in connection with this Agreement and for any other claim, shall be limited to the payments actually received by ArcLight from Client for the Services rendered to Client hereunder.

11. To the fullest extent permitted by law, Client shall indemnify ArcLight and each of its members, managers, officers, employees and agents, and hold each of them harmless, from and against any and all claims, demands, liabilities, damages and expenses arising out of or resulting from any intentional act, gross malfeasance or misfeasance, or negligence (either by act or omission) by Client or anyone for whose acts Client may be liable.

Accordingly, Client and ArcLight hereby sign this Agreement to be effective on Effective Date.

I have read the above agreement and accept the terms. I understand that ArcLight will only provide services after payment is received.

Signee Full Name(Required)

First Last

Please print your name, your "Electronic Signature" below:(Required)

Please leave any additional comments or instructions here:

by arclight1stg

Surrogate Health Insurance Search and Submission

X/Twitter

This field is for validation purposes and should be left unchanged.

Insured's Information

Insured's Full Name(Required)

First Middle Last

Insured's Date of Birth(Required)

Insured's Address(Required)

Street Address Address Line 2 City State ZIP Code

Insured's County(Required)

Insured's Phone(Required)

Insured's SSN(Required)

Insured's Email(Required)

Insurance Carrier Information

Does the insured currently have another active policy?(Required)

Yes

Insurance Carrier Name(Required)

In which state is the policy active?(Required)

State

Is this policy obtained through an employer or group plan?(Required)

(This could either be through either the insured's, the insured’s spouse’s, or the insured's parent's work.)

Yes

Please list the names and address for any doctors or medical facilities that you would like the new plan to cover:(Required)

Note: Your preferred OB-GYN and DELIVERY HOSPITAL must be listed on this Health Insurance Request Form. If this information is not included on our form at the time of submission, we cannot guarantee that the plan(s) that we find will consider these medical providers as In-Network Providers. If this information is given to us after we apply for these plans, there will be an additional fee to conduct further research to identify the correct medical group and/or look into changing the plan (during Open Enrollment).

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Are you an agency or an individual?(Required)

Agency

Individual

Agency Name(Required)

Full Name(Required)

First Last

Email(Required)

Phone Number(Required)

Signee Full Name(Required)

First Last

Please print your name, your "Electronic Signature" below:(Required)

Date(Required)

Please leave any additional comments or instructions here:

by arclight1stg

Surrogate Life Insurance Search and Placement

Insured's Information

Insured's Full Name(Required)

First Middle Last

Insured's Date of Birth(Required)

Insured's Address(Required)

Street Address Address Line 2 City State ZIP Code

Insured's Phone(Required)

Insured's SSN(Required)

Insured's Email(Required)

Insured's Employment Information

Employer Name(Required)

Employer Address(Required)

Street Address Address Line 2 City State ZIP Code

Job Title(Required)

Primary Beneficiary Information

Primary Beneficiary is the person who would receive the insured’s life insurance money should the insured pass away. If there is more than one person that you’d like to list as the Primary Beneficiary, please call us with the additional person or people’s names.

If you don't know this information right now, that is okay. We will obtain this information from you later when we complete your final application for Life Insurance.

Primary Beneficiary Name(Required)

First Last

Primary Beneficiary Date of Birth(Required)

Primary Beneficiary SSN(Required)

Primary Beneficiary Relationship to Insured(Required)

Secondary Beneficiary Information

The Secondary Beneficiary is the person who is second in line to receive the insured’s life insurance money in case the primary beneficiary is also deceased.

Secondary Beneficiary Name

First Last

Secondary Beneficiary Date of Birth

Secondary Beneficiary SSN

Secondary Beneficiary Relationship to Insured

Insured's Information (Continued)

Insured’s Annual Income(Required)

Insured’s Total Household Income(Required)

Insured’s Primary Physician Information

Primary Physician Name(Required)

First Last

Primary Physician Address(Required)

Street Address Address Line 2 City State ZIP Code

Has Insured had a DUI in the past 10 years?(Required)

Yes

Insured’s Health Insurance Carrier Name(Required)

For example: Anthem, Cigna, etc.

What death benefit is the insured requesting for this policy?(Required)

Will Intended Parents be added to the policy as beneficiaries?(Required)

Yes

Any additional Information you’d like to provide:

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Are you an agency or an individual?(Required)

Agency

Individual

Agency Name(Required)

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Signee Full Name(Required)

First Last

Please print your name, your "Electronic Signature" below:(Required)

Date(Required)

Please leave any additional comments or instructions here:

by arclight1stg

arclight1stg

Newborn Information

Delivery Hospital Information

Intended Parent Information

Send billing information to:

Intended Parent(s) Information

Send billing information to:

ArcLight Insurance Services, Inc. "ArcLight" shall provide the health insurance review services to the Client beginning on the Effective Date, subject to these Terms and Conditions (the "Agreement"):

Insured's Information

Insurance Carrier Information

Send billing information to:

Insured's Information

Insurance Carrier Information

Please upload the following documents, or email to submissions@arclightinsurance.com

If yes, please provide the login credentials below or email them to submissions@arclightinsurance.com.

Send billing information to:

ArcLight Insurance Services, Inc. "ArcLight" shall provide the health insurance review services to the Client beginning on the Effective Date, subject to these Terms and Conditions (the "Agreement"):

Insured's Information

Insurance Carrier Information

Please upload the following documents, or email to submissions@arclightinsurance.com

If yes, please provide the login credentials below or email them to submissions@arclightinsurance.com.

Send billing information to:

ArcLight Insurance Services, Inc. "ArcLight" shall provide the health insurance review services to the Client beginning on the Effective Date, subject to these Terms and Conditions (the "Agreement"):

Insured's Information

Insured's Employment Information

Primary Beneficiary Information

Secondary Beneficiary Information

Insured's Information (Continued)

Insured’s Primary Physician Information

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Applicant Information

Principal Officer(s) Details

Operations

What size contracts do you feel the applicant is qualified to do...

Additional Comments or Special Considerations

Personal Information

Pilot Qualifications

For Flight Instructors

Requested Coverage

(Please provide total aggregate limits for each)

Supplemental Questions

Aircraft Use Information

Coverage Needs

Insurance History

Additional Information

Applicant Infromation

Surrogacy Details

Coverage Needs

Medical & Pregnancy History (For Surrogate)

*You have indicated there is not currently a surrogate contract in place. This section will be skipped unless indicated otherwise.

Legal & Construction Information

Additional Information

Applicant Information

Property Information

Renovation/Construction Details

Occupancy & Rental Details

Safety and Protection

Insurance Coverage Needs

Claims History

Additional Properties

Additional Information