Healthcare Policy Application

HEALTHCARE POLICY APPLICATION

Applicant Information

Full legal name:

Employment and Current Coverage

Yes No

Dependents to Be Covered

Dependent 1 — Name: DOB: Relationship:

Dependent 2 — Name: DOB: Relationship:

Dependent 3 — Name: DOB: Relationship:

Medical History and Current Health

Diabetes Hypertension Heart disease Asthma/COPD Other

Yes No

Lifestyle and Physical Measurements

Proposed Coverage and Payment

Select desired plan (select one):

Basic Health Plan Standard Health Plan Premium Health Plan

Automatic bank draft Debit/Credit card Invoice / Bill me

Authorization, Certification and Privacy Acknowledgement

By signing below, I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any material misrepresentation or omission of fact may be grounds for rescission or denial of coverage, and may constitute insurance fraud under applicable law.

I authorize any physician, hospital, pharmacy, insurer, employer, or other custodian of my health information to release medical and other information necessary to underwrite and administer my application and any policy issued. I understand this authorization permits disclosure of medical information related to mental health, substance use, HIV/AIDS, and genetic testing where relevant to underwriting, except where restricted by law.

I acknowledge receipt of the privacy practices and agree to the insurer's use and disclosure of my health information for underwriting, claims processing, quality assurance, and as required by law. I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.

I have read and understand the statements above. I agree to the terms of this application and authorize verification of information.

Fraud Warning and Legal Notices

Any person who knowingly presents a false or fraudulent claim, or who knowingly presents false information in an application for insurance, may be subject to criminal and civil penalties, including fines and imprisonment, and may be required to repay claims paid on the basis of such information.

This application does not bind the insurer to issue a policy. Coverage will be effective only if a policy is issued and the first premium is paid as required by the insurer. The insurer reserves the right to request additional information, medical examinations, or records prior to making a final underwriting decision.

Acknowledgement of Authorization to Obtain Records

I authorize the release of medical, pharmacy, and other health-related information to the insurer and its agents for the purpose of underwriting and claims administration. I understand that information obtained may be used to determine eligibility for coverage and rate classification.

I acknowledge receipt of the insurer's privacy notice and consent to the use of my health information as described above.

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