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- This enrollment page is for INDEPENDENT CONTRACTORS (1099) ONLY
- Please return to previous page to fill out the census and intake form under GROUPS if you have any W2 employees at your company
Please answer the following questions for yourself, your spouse, and any dependents included in the application for coverage eligibility:
- Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for any of the following conditions: cancer, heart disease (including bypass), heart attack, heart surgery, or stroke?
- Has the prospective client or any of his/her dependents applying for coverage been home-bound, incapacitated, or incapable of self-support due to a medical condition within the past five years?
- Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for organ failure or an organ transplant involving the kidney, liver, lung, or heart, or for any form of organ support (e.g., dialysis)?
- Is the prospective client or any of his/her dependents applying for coverage currently pregnant or expecting?
- Has the prospective client or any of his/her dependents seeking coverage have an upcoming planned surgery?
If the account holder, their spouse, or any dependents answer “yes” to any of these questions, they will not be eligible for coverage. You can, however, find coverage options on www.healthcare.gov
If the account holder, their spouse, or any dependents answer “no” to ALL of these questions, you may use the link below to enroll in our program.
- All enrollments and payments must be made by the 15th of the month prior to the effective date.
- This form must be filled out by the prospective member on the plan and NOT the broker or agent.
- This plan requires submission of marriage and birth certificates for any legal dependents on the plan (If these are not submitted with the initial enrollment, claim payment for the dependent can be delayed up to 30 days after submission