APPLICANT
*
Gender
Male
Female
*
Date of Birth
(mm/dd/yyyy)
Include Spouse?
*
# of Children
None
1
2
3
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5
6
7
8
9
10
SPOUSE
*
Gender
Male
Female
*
Date of Birth
(mm/dd/yyyy)
PAYMENT OPTION
Monthly Payment
One Time Payment (Discounts Available)
COVERAGE PERIOD
*
# of Days
1
--Select--
30
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*
# of Months
--Select--
Up to 3 Months
Up to 6 Months
Up to 11 Months
*
Start Date
(mm/dd/yyyy)
*
End Date
(mm/dd/yyyy)
Start date must be at least 1 day in the future from the date
ZIP CODE
*
PLEASE CORRECT THE FOLLOWING
OPTIONS
Carrier
Plan
Deductible
Co Insurance
Rate
This quote includes...
QUOTE SUMMARY
Coverage for:
Location:
Date of Birth:
Coverage Period:
Duration:
IMPORTANT INFORMATION
This quote includes administration fees. This quote does not include a one-time enrollment fee.
MAKE SURE YOU UNDERSTAND AND AGREE WITH THE TERMS OF THE POLICY. PAY SPECIAL ATTENTION TO THE EFFECTIVE DATE, PREMIUM AMOUNT, TOTAL MONTHLY COST, BENEFITS, LIMITATIONS, EXCLUSIONS, AND RIDERS.
The actual cost of your policy may differ from the quote above due to rate increases or policy changes from the insurance carrier. (Rates are highly dependent on age.) The carrier you selected may not guarantee their rates for any period of time.
The Deductible amounts are your share of the costs for covered benefits. These amounts are subject to change.
Short Term Medical Insurance benefits are limited. Every applicant should review the plan benefits, exclusions and limitations by selecting topics from the above list.
This insurance is not available in all states and availability in a state may change. If you submit an application for a state where the plan is no longer available, your application and premium (if included) will be returned and no coverage will become effective.
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