Type of Enrollment
Effective Date & Product Service
Select or Create Case
Client Information
Current Insurance
Preferred Hospitals
Preferred OBs
Additional Products
Send Quote
Payment
Additional Information
Submission

1/12
Type of Enrollment

 All fields are required unless indicated by (optional) next to the field label

2/12
Effective Date & Product Service

 All fields are required unless indicated by (optional) next to the field label

Rush Fee Notice: ACA Open Enrollment Requests:

  • If an Open Enrollment ACA Policy Placement request is received after the deadline dates, then a rush fee will be applied.
    • Request received 12/6 with 1/1 effective date - $250 Rush Fee
    • Request received 12/9 with 1/1 effective date - $500 Rush Fee
    • Request received 12/12 with 1/1 effective date - $750 Rush Fee
  • For 2/1 Effective Dates that must be applied by 1/15 (including MA):
    • Request received 1/3 with 2/1 effective date - $250 Rush Fee
    • Request received 1/8 with 2/1 effective date - $500 Rush Fee
    • Request received 1/12 with 2/1 effective date - $750 Rush Fee
  • For 2/1 Effective Dates that must be applied by 1/31:
    • Request received 1/17 with 2/1 effective date - $250 Rush Fee
    • Request received 1/22 with 2/1 effective date - $500 Rush Fee
    • Request received 1/27 with 2/1 effective date - $750 Rush Fee


Rush Fee Notice: Special Enrollment Requests:

  • To ensure timely processing of urgent requests, the following rush fee policy applies to Special Enrollment Insurance submissions.
    • Requests submitted with a start date or coverage need within 5 business days of the submission date will incur a $250 Rush Fee to prioritize and expedite processing.
    • This fee covers immediate review, priority handling, and coordination with carriers to meet expedited timelines.
    • All rush requests must be submitted with full documentation and payment in order to begin processing.

3/12
Select or Create Case

  Legitimate email addresses for Gestational Carriers and Intended Parents are required. If client email needs to be updated, please provide the following information in the Additional Notes section: GC Name - email and/or IP Name - email. If client emails are not correct in the ART Risk portal, the clients will not receive quotes, emails and tasks needed to complete enrollment.

Select case

  Create new case

4/12
Client Information

Intended Parent Information

Address Information

Does the IP have a partner that is also involved in the surrogacy process?

Address Information

GC Information

GC's Address Information

5/12
Current Insurance

Does the gestational carrier have ANY other health insurance coverage in place as of today (this includes employer health, Medicaid/MediCal, TriCare, government subsidized ACA plan and/or individual coverage)?

6/12
Preferred Hospitals

Is there a preferred delivery hospital?
*If no, I understand a delivery hospital will need to be chosen from in-network hospitals after effective date.

7/12
Preferred OBs

Is there a preferred OB?
*If no, I understand an OB will need to be chosen from in-network providers after effective date.

8/12
Additional Products

I would like to receive information on the following products:

9/12
Send Quote

To whom shall we send this quote?

10/12
Payment

Is the same party responsible for the one-time service fee payment and binder (first month’s premium) payment?
Note: International payment methods are NOT accepted by insurance carriers for premium payments. You will need to select a different paying party for the binder.
Will the same payment method be used for the service fee and binder?
ART Risk's one-time service fee
Party responsible for binder
Document(s) To Sign

Any payment authorization(s) you may have to sign will appear below.

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Payment Authorization Complete!
Service Fee Payment Authorization Complete!
Binder Fee Payment Authorization Complete!

11/12
Additional Information

Please provide any additional information that would be helpful in guiding you through your journey (optional). For example, is your Gestational Carrier pregnant?

Reminder: Please note any change of client email address here. Please be sure to note the name associated with the email.

12/12
Submission

Before you complete your submission:

NOTE: ART Risk service fees will be invoiced upon receiving this quote request. If a quote request is canceled after the quote has been sent but before enrollment, you will receive a refund of the ACA Placement Fee, less a $250 Market Search Fee and any application rush fees incurred.

Client Acknowledgement

Please sign the client acknowledgement.

Select Your Desired Policy

What policy are you requesting a quote for?

Your Contact Info

Enter the following information into the fields below.

Sign Payment Authorization Forms

Instructions:

Please review and sign the following payment authorization form(s). Once all forms are signed, Click the Request Quote button below to complete the quote request process.

One Time Service Fee Authorization Form

Please sign the following authorization form for the one-time service fee:
One-Time Service Fee Authorization Complete!

Binder Fee Authorization Form

Please sign the following authorization form for the binder fee:
Binder Fee Authorization Complete!