URLThis field is for validation purposes and should be left unchanged.Insured's InformationInsured's Full Name(Required) First Middle Last Insured's Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Insured's SSN(Required)Insured's Email(Required) Insurance Carrier InformationInsurance Carrier Name(Required)Policy or Member Number(Required)Carrier Customer Service Phone Number (if known)Please upload the following documents, or email to submissions@arclightinsurance.comInsured’s Insurance ID Card (Front and Back) Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 10 MB, Max. files: 2. Insured's Driver's License (Front) Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 10 MB, Max. files: 1. Insured's Health Insurance Benefits Booklet Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 10 MB, Max. files: 10. Is this policy obtained through an employer or group plan?(Required) Yes No Employer’s Health Insurance Open Enrollment Date (if known) MM slash DD slash YYYY Is the policy obtained through a spouse's or parent's employer?(Required) Yes No Spouse's or Parent of Spouse's Name(Required)If under 26 and still claimed as a dependent by parent, please enter the parent's information as the primary policy holder. First Last Spouse's or Parent's Date of Birth(Required) MM slash DD slash YYYY Spouse's or Parent's SSN(Required)Spouse's or Parent's Phone (as on file with employer)(Required)Spouse's or Parent's Employer Name(Required)Is this policy obtained through a work union or the military?(Required) Yes No If yes, please explain:(Required)Does the Insured have a username and password set up to log into their online account with the above-mentioned carrier?(Required) Yes No If yes, please provide the login credentials below or email them to submissions@arclightinsurance.com. Note: This information will be stored only in our secure server.UsernamePasswordIf no, does the Insured authorize ArcLight Insurance to create an online account for them?(Required) Yes No (Note: This is important to obtain the Insured’s benefits package; login information will be given to the Insured once the account is created.) 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 an insurance review of the Insured’s health insurance policy on behalf of Client in an effort to determine if the policy is surrogacy-friendly and if Client’s obstetrician and delivery hospital are in-network with such policy (the “Services”). 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 $275 shall be due and payable by Client on the Effective Date for the Services of ArcLight and is nonrefundable in all cases. The fee for this service will increase to $350 each year during the individual market Open Enrollment period. Verification requests submitted within three days or fewer of the respective State’s Open Enrollment deadline, will incur additional fees: $100 for submissions made three days prior, $150 for those submitted the day before, and $200 for requests sent to us on the final day of Open Enrollment. These fees are in addition to the standard verification fees. These fees are non-refundable in the case of extenuating circumstances including, but not limited to, a retroactive extension of the Open Enrollment period. 3. Client represents and warrants that all information provided to ArcLight is complete and accurate. Client shall provide, and shall cause the Insured to 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 Client and the Insured in connection with the Services. The Insured shall, upon reasonable request, provide further information and be available for phone calls with the insurance carrier. 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 existing insurance policies of the Insured. 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, obstetrician and delivery hospital decisions shall be made by Client and the Insured 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, obstetrician 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 or the Insured. 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. 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. 10. This Agreement shall be governed by and construed in accordance with the laws of the State of California. 11. 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. 12. 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."Client" Full Name(Required) First Last Please print your name, your "Electronic Signature" below:(Required)Title Δ
