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Health assure application form

Assure form 2025

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4.8 out of 5

75 votes

The document is an ASSURE Self-Insured Application and Change Form used by employees to apply for or modify their health insurance coverage. It includes sections for personal information, coverage options, reasons for application or change, dependent information, and other insurance details. The form emphasizes the importance of accurate information and includes a confidentiality statement regarding the use of provided data.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (75 Votes)
2018	4.3 Satisfied (65 Votes)

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