Application form sample
This article presents the new Safelink application form. As you will be able to see, the new form contains more information than the previous version. For this reason, the entire document will be more extense (between 8 and 9 pages). Following, we will see each section in detail.
Header & Plan selection
All letters will have a header, which will include the applicant's name and their physical address on the top left side. Then, the rest of the information will depend on the type of applicant (regular / HMO) who submits the form.
Regular Applicants
In the case of regular applicants, the header first shows an introductory paragraph that presents the service. Then, it explains the main service advantages and informs about the basic eligbility requirements and proofs.
Afterwards, applicants will find the Plan selection. They will have to select only one of the two options: Keep Your Own Smartphone or Free Safelink Smartphone:
If both options are selected, BO agents should create the application by selecting the BYOP option, unless the applicant's Safelink cell phone number was not introduced in the application
Right below the plan selection options, a set of disclaimers will be available for applicants of different States. This means that they should only read the disclaimer that pertains to the State where they reside, if applicable. This means that applicants should only read this section if their State is mentioned in any of the disclaimers.
Additional info
There will be cases in which this page may contain further information depending on the State in question. Washington applicants will have to provide their 9-digit DSHS number and Florida applicants that apply through income must provide information in regards to their household income:
HMO Applicants
This is how the form will look like for HMO applicants. The full name and physical address will be displayed as usual at the left upper side, but then, instead of the plan options, we will find an introduction to Safelink that presents the service offer (free device, minutes and shipment, etc.) and some other features.
If applicants are interested in getting the service, they will find information in regards to the BYOP option (in case they want to use their own device) and also the different methods available to create an account (web, mail and phone):
At the bottom right corner of the form, the Promo code will be available. This code consists of ten characters and is used to identify enrollments from the SafeLink HMO channel. If BO agents need to create an enrollment for the applicant, this promo code must be introduced in the Promo code section while creating the account
Please, keep in mind that the 10-digit promo code will also be available at the top of the application. You can see it highlighted below. It will always consist of 10 digits:
For HMO applicant‘s, apart from the Selection of Plan and Phone Options, there will be a special consent verbiage in regards to the use of the applicant’s PII.
For Medicaid applicants, there will be a section for them to certify the participation in the Medicaid program. Followed by this agreement, applicants will have a to introduce their SSN number in the corresponding area:
Finally, there will be an explanation in regards to the service provided by Safelink as well as some reminders for applicants to know if the apply for the benefit. In case they are interested in receiving promotional offers, they can check the box provided:
Notice
In this section, applicants will find a set of information related to the legal aspects of the service that will be provided as well as some specifications in regards to the protection of the applicant's personal information, reason of data collection, requirements, etc.
This section is purely informative and applicants do not need to provide any kind of information in this page
Basic information about Lifeline
The first section of the following page presents the cases which would make a customer ineligible for the service and also provides a household definition, for the applicant to get clear concepts from the explanations that the form contains.
Afterwards, there are some tips and comments for the applicant to be aware on how to complete the form, apart from the necessary documentation that needs to be submitted to get qualified for the service:
Personal Information (part 1)
Here is where applicants will introduce their personal information. As usual, they will have to provide their first and last legal name. No abbreviations nor alias are accepted. They will also have to provide their date of birh and last four digits of the SSN (or Tribal Identification Number).
If they wish, applicants can also provide a phone number and email address for communication purposes. At the bottom of the section, they must select which communication channel is used to reach them:
Personal information (part 2)
In this section, applicants need to provide their home/physical address and select if it is a permanent or temporary residence. Applicants will also have to detail if they live in tribal lands, if applicable.
Apart from this, there will be another section to provide a shipping address, in case the applicant does not want to receive mailing at their physical address. This section must be completed with a valid shipping address if the applicant's physical address shows as invalid:
Personal information (part 3)
This section should only be completed if the one receiving the benefit is a child or dependent. For these cases, the legal guardian information has to be introduced in part 1 and the child or dependent's information should be provided here:
This section should be completed only if the child or dependent is the one participating in one of the qualifying programs
Qualification method
In this section, applicants will select their qualifying criteria. Most applicants qualify by participating in at least one of the government assistance programs, they should select as many programs as they receive.
On the other hand, applicants that don’t receive a government assistance program but have a household income below the Federal Poverty Guidelines, can apply via income using the guidelines provided on the income table:
Terms and Conditions
This page contains all the terms and conditions that applicants will have to accept by providing their initials in every single option. If any of the terms is not initialized, the application will be deemed invalid:
The terms and conditions will be considered as accepted only if the applicant provides their initials in every single box. If they check the boxes or fill them with any other symbol, the form will be deemed invalid. BO agents will have to create the form and reject it, leaving a note stating that the form has not been initialized correctly.
Sales person information
This final section will have to be completed if the application was completed by a Safelink representative:
