Individual Health Insurance Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Applicant Information
First Name
Required
MI
Required
Last Name
Required
Primary Phone Number
Required
E-Mail Address
Required
Social Security #
Required
Date of Birth
Required
/ /
Sex
Required
Street
Required
City
Optional
State
Required
ZIP / Postal Code
Required
Do you maintain a home in any other state/country?
Required
If yes, name of state/country
Optional
Number of months you live there each year
Optional
Billing Address
Required
City
Optional
State
Required
ZIP / Postal Code
Required
Are you eligible for Medicare?
Required
Are you covered under Other Health Coverage?
Required
If yes, why are you applying for individual coverage and what is your intended termination date?
Optional
Primary Care Provider Name:
Required
Current Patient
Required
Primary Care Provider Address
Required
City
Optional
State
Required
ZIP / Postal Code
Required
NPI #
Required
Loc Code
Required
Plan Options
Please select desired medical plan option.We cannot issue you a medical plan without a pediatric dental plan.
Unit
Required



Other Individuals Covered
Spouse/Civil Union Partner/Domestic Partner
First Name
Optional
MI
Optional
Last Name
Optional
Social Security #
Optional
Date of Birth
Optional
/ /
Sex
Optional
Home address same as applicant?
Optional
If no, provide home address and explain why the address is different:
Optional
Home Address
Optional
City, State. ZIP Code
Optional
Eligible for Medicare?
Optional
Covered under Other Health Coverage?
Optional
If yes, intended termination date
Optional
/ /
Primary Care Provider Name
Optional
Current Patient
Optional
Primary Care Provider Address
Optional
City, State. ZIP Code
Optional
NPI #
Optional
Loc Code
Optional
Child
First Name
Optional
MI
Optional
Last Name
Optional
Social Security #
Optional
Date of Birth
Optional
/ /
Sex
Optional
Living with applicant?
Optional
If no, please list address
Optional
City, State. ZIP Code
Optional
Eligible for Medicare?
Optional
Covered under Other Health Coverage?
Optional
If yes, intended termination date
Optional
/ /
Primary Care Provider Name
Optional
Current Patient
Optional
Primary Care Provider Address:
Optional
City, State. ZIP Code
Optional
NPI #
Optional
Loc Code
Optional
Race/Ethnicity
Your response is appreciated but NOT required. Choose a category that most closely describes you
Optional




Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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