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Click ‘Get Form’ to open the application miscellaneous download in the editor.
Begin with Part One, where you will select one of the options: New Policy, Add Dependent, Cancel Dependent, Upgrade, or Downgrade. Ensure you check only one box.
In Section A, provide details for each person applying for coverage. Fill in their names, Social Security numbers, sex, age, date of birth, height, weight, and contact information accurately.
Proceed to Section B to choose your desired coverage plan from the available options. Make sure to select only one deductible plan.
Complete Section C by providing billing information and selecting your preferred premium payment mode. Remember to include the nonrefundable application fee.
If applicable, fill out Part Two regarding health history and medical questions for all individuals applying for coverage. Be thorough and truthful in your responses.
Finally, ensure all required signatures are provided at the end of the document before submitting it through our platform.

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