Name:
Member #:
Address Type:	Home Business
Address:
City:
State:
Zip:
Home Zip:
Phone:
E-mail Address:
Fax:
Date of Birth:
Plan Type Requesting:	Individual & Family Health Savings Account Short-Term
Who's To Be Covered?	Self only Self & Spouse Self & Children Entire Family Spouse only Spouse & Children Children only
Spouse's Date of Birth:
Children's Ages:
Smoker:	No Yes In the past
If in the past, when did you quit?
Does anyone to be covered have any relevant health history?	Yes No
If yes, please explain:
Current Insurance Carrier:
Type of Current Coverage:	Group Individual COBRA None
Comments:

Applications are fully underwritten and may have limitations & exclusions.