Minimum Essential Coverage Enrollment

PLAN ENROLLMENT

Select Your Plan:*

Member - $45
Member + Child(ren) - $85.00
Member + Spouse - $85.00
Member + Spouse + Child(ren) - $125.00

MEMBER INFORMATION

Member Number

First Name*

Last Name*

Address*

Date of Birth*

Social Security Number*

Home Telephone Number

Cell Phone Number

Email Address*

Gender*

Marital Status*

Hidden

State*

Marriage Recorded

Hidden

County*

Marriage Recorded

SPOUSE/DOMESTIC PARTNER

Spouse/Domestic Partner Name*

Date of Birth*

Social Security*

Gender*

Is your spouse*

Date of Marriage*

Dependent 1

Dependent Name*

Social Security*

Date of Birth*

Gender*

Would you like to add a 2nd dependent?*

Yes
No

DEPENDENT 2

Dependent Name*

Social Security*

Date of Birth*

Gender*

Would you like to add a 3rd dependent?*

Yes
No

DEPENDENT 3

Dependent Name*

Social Security*

Date of Birth*

Gender*

Would you like to add a 4th dependent?*

Yes
No

DEPENDENT 4

Dependent Name*

Social Security*

Date of Birth*

Gender*

Do you want to add a 5th dependent?*

Yes
No

DEPENDENT 5

Dependent Name*

Social Security*

Date of Birth*

Gender*

Would you like to add a 6th dependent?*

Yes
No

DEPENDENT 6

Dependent Name*

Social Security*

Date of Birth*

Gender*

FORM AGREEMENT & SUBMISSION

Fraud Notice: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

YOU MUST SELECT THE CHECKBOXES BELOW AND SIGN:*

I UNDERSTAND AND AGREE