Healthcare Medical Plan Application

HEALTHCARE MEDICAL PLAN APPLICATION

Applicant Information

Date of Birth:    Gender: Male Female Non-binary / Other Prefer not to say

Emergency Contact

Employment & Sponsor Information

Employment Status: Employed Unemployed Retired Student

Plan Selection & Enrollment

Enrollment Type: New Enrollment Change / Open Enrollment Renewal

Desired Effective Date:

Coverage Level: Individual Two-person / Spouse Family

Plan Tier Preference: Bronze Silver Gold Platinum

Dependent Information (List family members to be covered)

Dependent 1

Dependent 2

Dependent 3 (if applicable)

Prior Coverage & Insurance History

Have you or any proposed dependent had health coverage in the past 12 months? Yes No

Medical History & Health Information

The following information is required for underwriting and to determine appropriate coverage. Failure to disclose or intentional misrepresentation may result in denial or rescission of coverage. Answer fully and accurately.

Tobacco use in past 12 months: Yes No

For females: Are you currently pregnant? Yes No Not applicable

Authorizations, Certifications & Privacy

I certify that the information provided in this application is true, complete, and correct to the best of my knowledge. I understand that intentional misrepresentation or omission of material facts may result in denial, modification, or rescission of coverage and may subject me to penalties under applicable law.

I authorize any physician, medical practitioner, hospital, clinic, laboratory, insurance company, or other organization, institution or person that has provided payment, treatment or supplies to me or my dependents to disclose to the plan administrator or its designees any information requested for the purpose of enrollment, underwriting, claims administration, coordination of benefits, or fraud investigation. This authorization includes the release of behavioral health and substance use records where permitted by law.

I understand that this authorization is voluntary and that a copy of this form shall be as valid as the original. I also acknowledge receipt of the Privacy Practices and agree that the plan may contact me regarding this application and my coverage, including electronic communications where consent permits.

By checking the box below I affirm the preceding statements and grant the authorizations required for processing this application. I agree and authorize the use and disclosure described above.

Attestation Regarding Payment Responsibility

I acknowledge that submission of this application does not relieve me of the obligation to pay premiums when due. Coverage, if approved, will be subject to the terms and conditions of the policy and any waiting periods. I understand that I am responsible for all premium payments and any cost-sharing required by the plan from the effective date of coverage.

Signature

If signing on behalf of the applicant, provide your authority to act (e.g., parent, legal guardian, power of attorney).

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