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Simplified Silver Application

Primary Spouse Medical Questions Additional Information Agreements Summary Billing Confirmation
Primary Insured Information

Simplified Silver Medical Plan

Payment Frequency

Monthly
Optional Coverage

Primary Insured (Age 40, Male)

Excess Coverage Rider
$X.00
Outpatient Prescription Drug Rider
$X.00
Cancer Treatment Rider
$X.00
Payment Breakdown

Base Premium $202.00
Optional Riders $128.00
Total Due $333.00/mo
Alex Morgan
•••• •••• •••• 4242
Expires 03/2030
Primary Insured Information

First Name
Middle Initial
Last Name
ID Type
Driver's License
TRN Number
Driver's License Number
Height (ft/in)
Weight (lbs)
DOB
Age
Sex
Male
Female
Smoker
Yes
Phone
Email (required, cannot be agent's email)
Country of Residence
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    "layout": "primary-info",
    "app": "enrollment",
    "brand": "default",
    "env": "proof",
    "method": "GET",
    "query": {
        "p": "enrollment/primary-info"
    },
    "url": "https://xpress.cremadesignstudio.com/enrollment/primary-info",
    "slug": "primary-info",
    "pathname": "enrollment/primary-info",
    "protocol": "https",
    "host": "xpress.cremadesignstudio.com",
    "hostname": "https://xpress.cremadesignstudio.com",
    "ip": "216.73.216.155",
    "lang": "",
    "title": "Primary Insured Information",
    "basePath": "https://xpress.cremadesignstudio.com",
    "languages": {
        "en": {
            "abbr": "ENG",
            "name": "English"
        },
        "es": {
            "abbr": "ESP",
            "name": "Spanish"
        }
    },
    "agent_page": false,
    "sidebar": true,
    "tools": false,
    "formID": "primaryInfo",
    "countries": [
        "Anguilla",
        "Aruba",
        "Bahamas",
        "Bolivia",
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        "Chile",
        "Colombia",
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        "Dominican Republic",
        "Ecuador",
        "El Salvador",
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        "Honduras",
        "Jamaica",
        "Mexico",
        "Nicaragua",
        "Panama",
        "Peru",
        "United States",
        "Uruguay",
        "Venezuela"
    ],
    "riders": [
        {
            "title": "Cash Value",
            "description": "Massa tincidunt nunc pulvinar sapien et ligula ullamcorper malesuada proin libero nunc consequat interdum varius sit amet mattis vulputate enim nulla aliquet porttitor lacus luctus.",
            "category": "disability",
            "url": "#modal-cash-value",
            "price": 100,
            "options": false
        },
        {
            "title": "Cash Value ROP",
            "description": "Massa tincidunt nunc pulvinar sapien et ligula ullamcorper malesuada proin libero nunc consequat interdum varius sit amet mattis vulputate enim nulla aliquet porttitor lacus luctus.",
            "category": "life",
            "url": "#modal-cash-value-rop",
            "price": 100,
            "options": false
        },
        {
            "title": "Critical Illness",
            "description": "Upon first diagnosis of internal cancer, heart attack, stroke, chronic kidney failure, or major organ transplant the Critical Illness Rider will pay to the insured the chosen benefit amount.",
            "category": "life",
            "url": "#modal-critical-illness",
            "price": 100,
            "options": true
        },
        {
            "title": "Waiver of Premium",
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            "category": "life",
            "url": "#modal-waiver-of-premium",
            "price": 100,
            "options": false
        },
        {
            "title": "Excess Coverage",
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            "category": "medical",
            "url": "#modal-excess-coverage",
            "price": 100,
            "options": true
        },
        {
            "title": "Maternity",
            "description": "Access the policy\u2019s great maternity benefits through purchasing this rider. To use these benefits, both the mother and father need to be insured for at least 10 months.",
            "category": "medical",
            "url": "#modal-maternity",
            "price": 100,
            "options": true
        },
        {
            "title": "Prescription Drugs",
            "description": "Adding a prescription drug rider can be a helpful addition to any medical policy. The Prescription Drug Rider is only available on first-time enrollment.",
            "category": "medical",
            "url": "#modal-prescription-drugs",
            "price": 100,
            "options": true
        },
        {
            "title": "30-Month Income Protection Rider",
            "description": "This Income Protection Rider pays $2,000 for up to 30 months if the insured cannot perform the material functions of their occupation due to illness or non-occupational injury.",
            "category": "medical",
            "url": "#modal-30-month-income-protection-rider",
            "price": 100,
            "options": true
        },
        {
            "title": "Dental and Vision Rider",
            "description": "Add Dental and Vision benefits to your medical plan. With a $50 Dental deductible and $0 Vision deductible, plus child coverage, this is a great deal.",
            "category": "medical",
            "url": "#modal-dental-vision-rider",
            "price": 100,
            "options": true
        },
        {
            "title": "Term Life Rider",
            "description": "This annually renewable life rider adds $10,000 of live coverage to your medical plan. This rider will term one the insured reaches age 70.",
            "category": "medical",
            "url": "#modal-term-life-rider",
            "price": 100,
            "options": true
        },
        {
            "title": "Outpatient Prescription Drug Rider",
            "description": "Increase your outpatient prescription benefit to $2,500 per person per year. This benefit will cover brand name drugs in your country of residence and generic drugs in the U.S.",
            "price": 46
        }
    ],
    "riderMapping": {
        "excessCoverage": "Excess Coverage Rider",
        "outpatientRx": "Outpatient Prescription Drug Rider",
        "cashProtector": "Cash Protector Rider",
        "cancerTreatment": "Cancer Treatment Rider"
    },
    "paymentModes": {
        "Monthly": "mo",
        "Semiannual": "semi",
        "Annual": "yr"
    },
    "request": {
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        "method": "GET",
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        },
        "url": "https://xpress.cremadesignstudio.com/enrollment/primary-info",
        "slug": "primary-info",
        "pathname": "enrollment/primary-info",
        "protocol": "https",
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        "hostname": "https://xpress.cremadesignstudio.com",
        "ip": "216.73.216.155",
        "lang": "",
        "title": "Primary Info"
    },
    "site": {
        "name": "MWG Agent Quoter",
        "gtag": "",
        "author": {
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            "email": "callaginn@users.noreply.github.com",
            "url": "https://cremadesignstudio.com/staff/callaginn"
        },
        "logo": "/enrollment/assets/img/logo.svg"
    },
    "id": "default",
    "cdn": "https://cdn.cremadesignstudio.com",
    "enrollment": {
        "plan": {
            "name": "Simplified Silver Medical Plan",
            "policyNumber": "SSM-2025-00ABC123",
            "effectiveDate": "2025-10-01",
            "premiumMode": "Monthly",
            "premium": {
                "base": 202,
                "riders": 128,
                "fees": 3,
                "total": 240
            }
        },
        "primary": {
            "idType": "Driver's License",
            "idNumber": "A123-456-789",
            "name": {
                "first": "Alex",
                "middle": "J",
                "last": "Morgan"
            },
            "dob": "1985-03-14",
            "age": 40,
            "gender": "Male",
            "smoker": false,
            "height": "5'10\"",
            "weight": "180 lb",
            "countryOfBirth": "United States",
            "phone": "(555) 123-4567",
            "email": "alex.morgan@example.com"
        },
        "spouse": {
            "coverage": true,
            "idType": "TRN Number",
            "idNumber": "TRN-492-10-384",
            "name": {
                "first": "Taylor",
                "middle": "R",
                "last": "Morgan"
            },
            "dob": "1987-09-21",
            "age": 38,
            "gender": "Female",
            "smoker": false,
            "height": "5'6\"",
            "weight": "135 lb",
            "countryOfBirth": "United States",
            "phone": "(555) 987-6543",
            "email": "taylor.morgan@example.com"
        },
        "demographics": {
            "occupation": "Project Manager",
            "countryOfResidence": "United States"
        },
        "addresses": {
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                "street": "123 West Elm St",
                "city": "Jackson",
                "zip": "39201",
                "country": "United States"
            },
            "mailing": {
                "street": "PO Box 456",
                "city": "Jackson",
                "zip": "39205",
                "country": "United States"
            }
        },
        "employer": {
            "name": "Acme Manufacturing",
            "type": "Manufacturing",
            "phone": "(601) 555-7788",
            "address": "200 Industrial Park Dr, Jackson, MS 39201",
            "duties": "Oversee production schedules and vendor relations"
        },
        "riders": {
            "primary": {
                "excessCoverage": true,
                "outpatientRx": true,
                "cashProtector": false,
                "cancerTreatment": true
            },
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                "excessCoverage": false,
                "outpatientRx": true,
                "cashProtector": false,
                "cancerTreatment": false
            }
        },
        "physician": {
            "name": "Dr. Jamie Patel",
            "phone": "(601) 555-2211",
            "address": "400 Health Way, Suite 210, Jackson, MS 39216"
        },
        "payment": {
            "method": "Credit Card",
            "mode": "Monthly",
            "card": {
                "brand": "Visa",
                "holder": "Alex Morgan",
                "last4": "4242",
                "exp": "03/2030"
            },
            "wire": null,
            "check": null
        }
    },
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        "Spouse": "/enrollment/spouse-info",
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        "Agreements": "/enrollment/simplified-silver-medical/agreements",
        "Summary": "/enrollment/summary",
        "Billing": "/enrollment/billing",
        "Confirmation": "/enrollment/confirmation-simple"
    },
    "indexes": {
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        "spouse-info": 1,
        "questions": 2,
        "additional-info": 3,
        "agreements": 4,
        "summary": 5,
        "billing": 6,
        "confirmation-simple": 7
    },
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    "formAction": "/enrollment/spouse-info"
}