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Maternity Benefits Application Form

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!

 

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:


How'd you find us?         

Your Current State of Residency?  
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?
 

Please Click next to the Plan(s) you wish to apply for:
You can choose one or both of the options below...

 

 # Monthly Rate Couple
Rate		 2 Day
Benefit		 4 Days
Benefit

Application Notes:
1 $107.07 N/A $3,145 $4,345 Wife Only Covered
 
Contact Info
Mailing Address
  		 City
 		 State
 Zip
 
Phone  ()  ie (602) 555-1212

Email Address  
 		  
Current Health Insurance Company   (ie SelectHealth, Blue Cross Blue Shield, etc)
Current Health Insurance Deductible    (ie $1,000, $500, etc)
Current Health Insurance Policy #  (If you don't have it, you can fill in later on the form)
Current Health Insurance Effective Date   (ie When the policy was put in force, apx date OK)
Current Health Insurance - Employer/Group Coverage  OR Individual/Family Coverage
On your current Health Insurance Plan:
Maternity is: Covered as any sickness  OR
  NOT Covered at all    OR
  Covered but with this deductible:
 
Wife / Female Info
Last Name
  		First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
  		Weight (ie 135)
  lbs		 Birth State (ie UT))
 Smoker?
 No       Yes    		  

Wife Cell Phone   (If any - Not on application, just for contact if underwriting needed)


Employment  Information

Hours/wk     Title/Duties:
Employer:    Time with Company (ie 3 yrs)
Please Click Below to verify that you understand the following:
I am NOT Pregnant now and understand that no benefits will be paid for delivery within the first 10 months of the plan being in force.
 
Husband / Male Info
(Note: Husband is Covered on Option #2 - Enter First two lines even if not choosing option #2)
Last Name
 		 First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
  

Husband Cell Phone   (If any - Not on application, just for contact if underwriting needed)
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).
 Payment Info - Choose from Bank or Credit Card info below for payment of the plans chosen
 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: 
 Bank Name:   Bank City State   Zip 
 Get the following Information from the bottom of your check:
 Routing Number               Account Number
 ':   123456789      ':        123   45678  9        ||'    1234  (Check number)
 ': ': ||'    Don't need check number
 
 For your convenience, Aflac (#1) & DefinedMed (#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
 

 Credit Card Option  
 ($107.07/month - Wife only):

 Credit Card Type (Choose ONE)-    Visa        MC       American Express   
 Credit Card Number    
 Expiration Date (mm yy):  

Enter Questions or Comments Below,
Enter the Code, then Submit Button to get an application...

  To Validate your submission,                        
Type this number:                          
in this box here >>>   <<< 
Note: if you don't type in this exact number, your submission
 will not be recorded! 

Then click SUBMIT below...



Remember that your ZIP CODE will be your password to open the
Adobe PDF Application you will receive by email

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