Maternity
Benefits Application Form
Arizona |
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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...
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If you have delivered a baby, was your LAST delivery a
Normal
delivery or
C-Section
delivery?
(If you are planning a C-Section for your next delivery, then you can
choose BOTH of the options below. If you are planning a normal vaginal
delivery, then you might just choose option #1 below) |
Please Click next to the Plan(s) you wish to apply for: |
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* Rates below for Option #3 above. Both spouses
must be covered
Ages 15-34 - $161.88
Ages 35-44 -
$188.80
Ages 45-54 - $266.90
What date would you like the plans to start?
(mm/dd/yyyy)
(blank if ASAP, or pick a future date)
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Contact Info |
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Current
Health Insurance Plan Information (Required) |
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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 #
(Important to apply for the plan!) |
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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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Wife State of Birth
(ie: Utah, CA, or Alberta Canada, etc) |
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Employment Information
- Wife
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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 is Covered on Option #2 - Enter First two lines even if
not choosing options #1 and/or #3) |
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Husband Cell Phone
(If any - Not on application, just for contact if underwriting needed) |
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Last Doctor Visit Information
(Husband) |
Employment
Information
- Husband
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Hours/wk
Title/Duties:
Employer:
Time with Company (ie 3 yrs)
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Payment Info
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Choose from Bank or Credit Card info below for payment of the plans
chosen
NOTE: Option #1 & #2 -
Bank or Credit Card (No fee added)
Option #3 -
Bank account ONLY
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Bank
Selection - Enter
information below ONLY if you want the premiums to come out of a Bank
Account
Use
Bank below for Option #1 and/or #2
Use
Bank below for Option #3
Use the following bank
information for:
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Bank Name:
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Bank Address
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Bank State
Bank 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 #1 & #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
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Use
Credit Card below for Option #1 and/or #2 (No Fee)
Credit Card Type (Choose ONE)-
Visa
MC
American
Express
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Credit Card Number
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Expiration Date (mm yy): |
