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Hospital Supplemental Information Request

Note: This is NOT an application, but a request for an agent to contact you for an application. Thanks!

Please click on circle buttons CAREFULLY! 
For some reason it is hard to "Unselect" an "Circle Button" after you select it. If you mess up, you can press the following to reset the entire form. But remember, you will basically start over!  
Reset Form Here:


How'd you find us?                

Your Current State of Residency?  
 
Qualifying Question:  Have you delivered a child before? Yes  No   AND...
 
If you have delivered a baby, was your LAST delivery a  Normal delivery  or  C-Section delivery?

(If you are planning a C-Section for your next delivery, then you can choose BOTH of the options below. If you are planning a normal vaginal delivery, then you might just choose option #1 below)

Please Click next to the Plan(s) you wish to apply for:
You can choose one or both of the options below...

 

 # Female Only
Monthly Rate		 Couple
Rate		 2 Day
Benefit		 4 Days
Benefit

Application Notes:
1 $102.09 $204.18 $3,145 $4,345 Wife Only Coverage is Allowed
2 N/A *$97 apx $1,450 $2,900 Cover's C-Sec only, both spouses must be covered
3 23.40 $46.80 $1,400 $2,800 Specified Benefit (ICU) Plan- Can add child at birth
4 N/A $161apx $3,000 $5,000 Husband Wife Coverage Only - 1st & 15th Start only

What date would you like the plans to start? (mm/dd/yyyy)  (blank if ASAP, or pick a future date)

* Rates below for Option #2 above. Both spouses must be covered
Age Monthly
18-24 $27.54
25-29 $31.07
30-34 $31.91
35-39 $33.42
40-44 $36.83
45-49 $43.76
50-54 $50.66
55-59 $71.93
60-64 $96.70

add $35 plus $4.80 for each additional child to be covered

 Option #2 Above - Example Rate Calculation:
Male Age 25, Female Age 23 (Couple Only Coverage)
$31.07 + $27.54 = $58.61 / month + $34.39/mo
for the 2nd Policy (Wife only needs to be covered)   Total: $93.00

Benefit is $725/day x 4 days (C-Sec) = $2,900

Remember: These benefits can be used for any medically necessary hospitalization and up to 10 office visits at $75/visit per couple per year, and an additional 5 office visits at $75/visit between all children to be covered.
 
Contact Info
Mailing Address
  		 City
 		 State
 Zip
 
Phone  ()                                 ie (602) 555-1212

Email Address  
 		  
Current Health Insurance Plan Information (Required)
Current Health Insurance Company   (ie SelectHealth, Blue Cross Blue Shield, etc)
Current Health Insurance Deductible    (ie $1,000, $500, etc)
Current Health Insurance Policy #  (Important to apply for the plan!)
Current Health Insurance Effective Date   (ie When the policy was put in force, apx date OK)
Current Health Insurance - Employer/Group Coverage  OR Individual/Family Coverage
On your current Health Insurance Plan:
Maternity is: Covered as any sickness  OR
  NOT Covered at all    OR
  Covered but with this deductible:
 
Wife / Female Info
Last Name
  		First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
  		Weight (ie 135)
  lbs		 Smoker?
 No       Yes     

Wife Cell Phone   (If any - Not on application, just for contact if underwriting needed)

Wife State of Birth   (ie: Utah, CA, or Alberta Canada, etc)


Employment  Information - Wife

Hours/wk     Title/Duties:
Employer:    Time with Company (ie 3 yrs)
Please Click Below to verify that you understand the following:
I am NOT Pregnant now and understand that no benefits will be paid for delivery within the first 10 months of the plan being in force.
Husband / Male Info
(Note: Husband is Covered on Option #2 - Enter First two lines even if not choosing options #1 and/or #3)
Last Name
 		 First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
 		 Weight (ie 135)
  lbs		 Smoker?
 No       Yes    
Husband Cell Phone   (If any - Not on application, just for contact if underwriting needed)
Last Doctor Visit Information (Husband)

Employment  Information - Husband
Hours/wk    Title/Duties:
Employer:    Time with Company (ie 3 yrs)
 
 Payment Info - Choose from Bank or Credit Card info below for payment of the plans chosen

 
 NOTE: Option #1 & #3 - Bank or Credit Card (No fee added)
            Option #2 & #4 - Bank account ONLY
 Bank Selection - Enter information below ONLY if you want the premiums to come out of a Bank Account

 Use Bank below for Option #1 and/or #3
 Use Bank below for Option #2 and/or #4

 Use the following bank information for: 
 Bank Name:    
Bank Address
Bank State         Bank Zip 
 Get the following Information from the bottom of your check:
     Routing Number                   Account Number
 ':   123456789      ':        123   45678  9        ||'    1234  (Check number)
 ': ': ||'    Don't need check number
 
 For your convenience #1 & #2  will accept a credit card as payment.
 If you would like to pay by that method, enter the information below:
 Note: if you leave the sections below blank, we will process everything through the bank account above.
 You will need to send in a VOID check with your signed paperwork the start the plans
 

 Credit Card Option  

Use Credit Card below for Option #1 and/or #3 (No Fee)

 Credit Card Type (Choose ONE)-    Visa       MC  American Express
 
 Credit Card Number    
 Expiration Date (mm yy):  

Enter Questions or Comments Below,
Enter the Code, then Submit Button to get an application...

Please type in a short summary of the plans you want to apply for
(just to verify) and also any questions/ notes, etc.

  To Validate your submission,                        
Type this number:                          
in this box here >>>   <<< 
Note: if you don't type in this exact number, your submission
 will not be recorded! 

Then click SUBMIT below...



Remember that your ZIP CODE will be your password to open the
Adobe PDF Application you will receive by email

  
 

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