Medical Insurance Application Form

MEDICAL INSURANCE APPLICATION FORM

Applicant Information

Policy Details

Individual   Family   Group

Start Date:    End Date:

Monthly   Quarterly   Annual

Coverage Options

Select desired coverages (checked items will be included in the initial quote and form the basis of any policy issued):

Inpatient Hospitalization
Outpatient Services
Maternity Care
Dental
Vision
Prescription Drugs
Mental Health and Substance Use Disorder
Emergency Services
Preventive and Well Care

Exclusions and Limitations

The following are examples of typical exclusions and limitations. Coverage, limits, and exclusions will be governed by the policy document issued if this application is accepted. Common exclusions include, but are not limited to: treatment for cosmetic procedures, injuries sustained while committing a criminal act, services not medically necessary as defined by the insurer, experimental or investigational treatments, and pre-existing conditions subject to any waiting period expressly stated in the policy. Applicants are required to review the policy terms upon issuance.

I acknowledge that I have read and understand the exclusions and limitations described above and in any policy issued.

Medical History and Risk Information

To the best of your knowledge, answer the following. Incomplete or inaccurate information may result in rescission, denial of benefits, or criminal penalties where applicable.

Have you used tobacco or nicotine products in the last 12 months?    Yes   No

Previously insured?    Yes   No

Beneficiary Designation

Declarations, Authorizations, and Acknowledgements

I certify that the statements and answers contained in this application are true, complete, and correctly recorded to the best of my knowledge and belief. I understand that any material misrepresentation, omission, or concealment of fact may be grounds for denial of benefits, cancellation or rescission of coverage, or criminal penalties as provided by law. I authorize any licensed physician, medical practitioner, hospital, clinic, or other medically related facility, as well as any insurer, to release to the insurer all medical information, records, and employment-related health information necessary to underwrite or administer my application and policy. I authorize the insurer to obtain copies of my medical records and other information relevant to this application and to disclose such information to reinsurers or as required by law. This authorization shall remain valid for the duration necessary to process this application and any claim thereunder.

I acknowledge that premium payment is required for coverage to become effective and that coverage is subject to the terms, conditions, limitations, and exclusions of the policy issued. I understand that acceptance of this application is contingent upon underwriting review and that no statement herein shall bind the insurer unless and until a policy is issued and premium is received in accordance with policy terms.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company submits an application containing false information, or conceals for the purpose of misleading information concerning any material fact, may be guilty of insurance fraud and subject to civil or criminal penalties including denial of benefits.

Applicant acknowledges receipt of any required notices provided contemporaneously with this application and understands that terms of coverage, effective dates, and conditions of eligibility will be specified in the policy documents issued by the insurer.

Authorization to Bill and Premium Payment

I authorize the insurer to bill me for premiums due under any policy issued pursuant to this application. I understand that failure to pay premiums in accordance with the policy may result in lapse or termination of coverage. If I provide bank or payment information, I authorize the insurer to initiate debits for premiums as indicated on billing agreements provided separately.

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