HRINJ

* Staff

* Caller Name

Hi _____. How can I help you?

* Nature of the Call

Repeat Caller

General Question

Billing & Enrollment Concerns : 855-465-5270

Medical Claims/Coverage Questions : 732-529-8700

Provider Participation/Rx Coverage Inquiry

SALES Individual

SALES Small Business

RENEWAL Individual

RENEWAL Small Group

How did you hear about Health Republic Insurance of New Jersey?

* How did you hear about us?

TV, Radio, Newspaper or on-line digital advertisement.

HRINJ website

Healthcare.gov website

An outside event or meeting

Word of Mouth/Referral

Not Applicable (for repeat callers)

QUALIFYING QUESTIONS
Okay, I can help you with that.I just need to gather some information...

* Application Name

* Phone Number

* Email

Before I proceed ________, have you or any of your family members that you're going to cover experience any life changing event that could qualify you for the Special Enrollment Period?

* Qualifying Life Events

Was this within 60 days from today (30 days for emplyer-based coverage)?

* Date of QLE

Month	Day	Year