Applicant Info

Effective Date

Posted to Quotit as MM/DD/YYYY

Insurance Type

Plan Type (optional)

Current Premium (optional)

ZIP Code

First Name (optional)

Last Name (optional)

Phone (digits only)

Street (optional)

City (optional)

State (2 letters, optional)

County

Comments (optional)

Household Size (optional)

Household Income (optional)

Date of Birth

Posted as MM/DD/YYYY

Sex

Smoker?

If Yes and no date, they assume currently smoking

Date Last Smoked (optional)

Posted as MM/DD/YYYY

Type a generic name → choose allowed dosage. If multiple products exist, pick a Product / Route (NDC).

Contact Drugs Endpoint URL

RemoteAccessKey

WebsiteAccessKey

FamilyId

ContactId