Healthy Care Plan Enrollment Portal

 
 

View Policy Cost
& Benefits

Prefer to submit your application by mail?

Would you like to upload a census?

Agent's Information

Agent's Name *
Agent's Name

Plan & Enrollees

Please choose carefully. EE: Individual | ES: Individual & Spouse | EC: Individual & Child(ren) | EF: Family

Primary Policy Holder

Effective Date *
Effective Date
Term Date *
Term Date
Date of Birth *
Date of Birth
Gender *
Address *
Address
Phone *
Phone

Spouse

Date of Birth
Date of Birth
Gender

Dependent One

Date of Birth
Date of Birth
Gender

Dependent Two

Date of Birth
Date of Birth
Gender

Section 2A

Do you have other dependents you want to enroll?
Have you or any of your dependents been covered by anyother MEDICAL plan besides your current employer's plan within the past 12 months (this includes any other employer sponsored medical plan, Medicaid, Medicare, Champus, Tricare, etc.) *
If you answered "Yes", please fill out the rest of the questions.
Effective Date
Effective Date
Term Date
Term Date
Who Was Covered on the Policy?

Section 2B

Will you or any of your dependents be covered under another MEDICAL plan while covered under this EBA plan offered by your employer? *
This includes Medicaid, Medicare, Champus, Tricare, etc.) If you answered "Yes" please answer the remaining questions.
Effective Date
Effective Date
Who is covered by the policy?

Signatures

Acknowledgement of Pre-Existing Conditions Policy *
Terms & Conditions *
Payment Authorization *
Electronic Signature *
Electronic Signature
By writing my name below, I, the policy holder certify that I am above the age of 18, and have completed this form acuratly and the best of my knowledge.
Today's Date *
Today's Date
Include a $30 application fee and/or $10 credit card convenience fee.
$