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THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.

By checking this box, I confirm my understanding that this hospital care policy does not meet the federal government requirement for minimum essential health coverage.

SECTION 1 – PERSONAL IDENTIFICATION

Name (First, MI, Last):

Social Security #:

Home Address:

City:

State:

Zip:

County:

Occupation:

Height (ft-in):

Weight (lbs.):

Date of Birth:

Birth State or Country:

Gender:

Home Phone:

1. Are you a US citizen? YESNO

2. If no to question 1, are you a USA Resident and lived continuously in the US for the last 6 months? YESNO

SPOUSE* & CHILDREN INFORMATION - Complete if Applying for Dependent’s Coverage

Full Name (spouse):

Domestic Partner: YESNO

Occupation:

Gender:

Date of Birth:

Birth State or Country:

Height ft /in:

Weight:

Full Name (child):

Gender:

Date of Birth:

Birth State or Country:

Height ft /in:

Weight:

Full Name (child):

Gender:

Date of Birth:

Birth State or Country:

Height ft /in:

Weight:

Full Name (child):

Gender:

Date of Birth:

Birth State or Country:

Height ft /in:

Weight:

SECTION 2 - PLAN SELECTION

CHECK COVERAGE DESIRED:

Applicant

Applicant & Spouse

Applicant & Children

Applicant, Spouse & Children

Hospital Confinement Plan(s):

Plan I

Plan II

Plan III

SECTION 3 - MEDICAL INFORMATION

1. To the best of my knowledge, is anyone to be covered currently confined in a hospital or nursing home, or been recommended by a licensed physician?

YESNO

2. To the best of my knowledge, has anyone to be covered been confined in a hospital or nursing home within 12 months because they were diagnosed or treated by a licensed member of the medical profession for internal cancer, melanoma, heart surgery, heart attack, congestive heart failure, vascular disease, hypertension, chronic obstructive pulmonary disease, chronic liver disease, stroke, emphysema, sickle-cell anemia, asthma, chronic bronchitis, Parkinson's disease, multiple sclerosis, or rheumatoid arthritis?

YESNO

3. To the best of my knowledge, has anyone to be covered ever been diagnosed or treated by a licensed the medical profession for: Alzheimer's disease, senile dementia, systemic lupus, kidney failure, diabetes, or alcohol or drug abuse?

YESNO

4. To the best of my knowledge, has anyone to be covered tested positive for exposure to the Human Immunodeficiency Virus (HIV) infection or been diagnosed by a licensed member of the medical profession as having AIDS Related Complex or Acquired Immunodeficiency Syndrome (AIDS) caused by the HIV infection or other sickness or condition derived from such infection?

YESNO

5. Are you currently pregnant?

YESNO

6. Que yo sepa, ¿alguna de las personas cubiertas ha sido diagnosticada o tratada de hipertensión (tensión arterial alta) por un médico colegiado?

YESNO

If “Yes,” list person(s), medications taken, medication dosage and last two blood pressure readings.

Medication, Dosage, Readings with Dates:

The person(s) named above in questions 1 through 6 may be excluded from coverage by an Exclusion rider to be signed by the applicant prior to policy issuance.

7. Name, address and phone number of the personal physician(s):

Give details for “yes” answers to any questions and indicate to whom answers relate.

SECTION 5 – AUTHORIZATION

1. ¿Alguna de las personas que solicitan cobertura tiene actualmente una póliza de indemnización hospitalaria con nosotros o con alguna compañía?

YESNO

If yes, give name of company, list type of policy and amount of coverage.

2. REPLACEMENT: Is this insurance to replace or change other insurance?

YESNO

If “Yes”, give details including name of company