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Maternity
Benefits Application Form |
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The following form is sent
through
secure encryption directly to our secure server. You
will receive an application by email that will be filled out
based on your information you enter below. The filled in
application forms will be emailed to you PASSWORD PROTECTED
using your Zip Code as your password to open the form. This
is done to avoid someone getting your info by accessing your
email. Note: the email you receive will NOT remind you that your
password will be your Zip Code. The Email you receive will have
instructions on how to get the application back to be processed (Fax
or emailed back). After you press the "SUBMIT" button, a
representative will contact you to go over the following information
and explain all the details. Finally, please fill in every field as
best you can. If you miss something we can enter it manually on the
application later, but it may delay the start date. Thanks! |
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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:
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How'd you find us?
Your Current State of Residency? |
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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?
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Please Click next to the Plan(s) you wish to apply for
(Can't choose BOTH 1 and 2): |
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RRates below for Option #3 above. Both spouses
must be covered
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Age |
Monthly |
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18-24 |
$27.54 |
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25-29 |
$31.07 |
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30-34 |
$31.91 |
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35-39 |
$33.42 |
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40-44 |
$36.83 |
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45-49 |
$43.76 |
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50-54 |
$50.66 |
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55-59 |
$71.93 |
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60-64 |
$96.70 |
add $35 plus $4.80 for each
additional child to be covered |
Option #3 Above - Example Rate
Calculation #1:
Male Age 25, Female Age 23 (Couple Only)
$31.07 + $27.54 = $58.61 / month
Option #3 Above - Example Rate Calculation #2:
Male Age 25, Female Age 25 Plus 3 children
$31.07 + $31.07 + $49.40 = $111.54 / month
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.
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Contact Info |
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Current Health Insurance Company
(ie SelectHealth, Blue Cross Blue Shield, etc) |
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Current Health Insurance Deductible
(ie $1,000, $500, etc) |
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Current Health Insurance Policy #
(If you don't have it, you can fill in later on the form) |
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Current Health Insurance Effective Date
(ie When the policy was put in force, apx date OK) |
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Current Health Insurance -
Employer/Group Coverage OR
Individual/Family Coverage |
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On your current Health Insurance Plan: |
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Maternity is: |
Covered
as any sickness
OR |
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NOT
Covered at all OR |
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Covered
but with this deductible:
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Wife / Female Info |
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Wife Cell Phone
(If any - Not on application, just for contact if underwriting needed) |
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Pap Smear Information |
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Wife Last Pap Smear Date:
Pap Smear Doctor Name
Pap Smear Doctor Address, City Zip
Pap Smear Doctor Phone
Results (ie Pap Smear was Negative)
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Last Doctor Visit Information
(Wife) |
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Date that Wife / Female was last seen
by Doctor:
Check here
if this is the same doctor info from above (if so, then skip to
"Employment Information" below"
Doctor Name
Doctor Address, City Zip
Doctor Phone
Results (ie All fine, or what was prescribed, etc)
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Employment Information
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Hours/wk
Title/Duties:
Employer:
Time with Company (ie 3 yrs)
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Please Click Below to verify that you
understand the following: |
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Husband / Male Info
(Note: Husband can be covered on any options above (Enter the first line
below if Husband is NOT to be covered) |
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Husband Cell Phone
(If any - Not on application, just for contact if underwriting needed) |
Employment
Information
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Hours/wk
Title/Duties:
Employer:
Time with Company (ie 3 yrs)
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What date would you like the plans to start?
(mm/dd/yyyy)
(blank if ASAP, or pick a future date) |
Note: We will try to get the
effective date as close to the requested date as possible. Average is
3-5 business days after the application is received. All plans have a 10
month waiting period meaning you have to deliver in month 11 or beyond.
Effective dates can be any date from the 1st to 28th of the month only.
Although these supplemental policies can be used for maternity
hospitalizations, remember that you can use this policy for any covered
hospitalization that is medically necessary (see contract for exclusions
and limitations).
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Payment Info
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Choose from Bank or Credit Card info below for payment of the plans
chosen
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Bank
Selection - Enter
information below ONLY if you want the premiums to come out of a Bank
Account
Skip this section if you wish to use a Credit Card only...
Use the following bank
information for:
All
Maternity Options selected above
Option
#1 ONLY (See Chart above)
Option
#2 ONLY (See Chart above)
Option
#2 ONLY (See Chart above)
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Bank Name:
Bank City
State
Zip
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Get the following Information from the bottom of
your check: |
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Routing Number
Account Number |
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': 123456789
': 123 45678
9 ||' 1234
(Check number) |
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':
':
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Don't need check number |
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For your convenience, Option #1 & Option #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 |
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Credit
Card Option
Note: you can use Visa & MC or Amex only on
Option #1 & #2 (Option 3 MUST be BANK ONLY) |
Option #1 OR #2 ($104.04/month
OR $122.11/mo - Wife
only):
Credit Card Type (Choose ONE)-
Visa
MC
American
Express |
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Credit Card Number
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Expiration Date (mm yy): |
