AllUtahHealthPlans.com

Your Best source in Utah for
Family & Individual Health Insurance
Major Medical Health Insurance
HSA - Health Savings Accounts
Accident Insurance
Disability Income Insurance
Short Term Health Plans
Life Insurance and more!
(801) 406-9502

HomeHealth InsuranceHospital IndemnityDisabilityAccidentLife InsuranceDentalShort TermMedicareContact Us
Hospital Indemnity / Supplemental Plans -  Application Request Form
 UTAH
 

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 State of Residency?  
Click beside the number of each plan you wish to apply for.
 

Choose any or all plans below:

 

 # Single
Rate		 2-Party
Rate		 Family
Rate		 2 Day
Benefit		 4 Days
Benefit

Application Notes:
1 $35 $75 $90.00 $3,000 $3,000 Through your employer group with at least 3 employees in the company.

Note: If you are choosing #1 Above, click all that apply below:  
I am OR  My Spouse is Self Employed with employees? If so How many Employees?
OR If you are NOT Self Employed...
 I am AND/OR  My Spouse is an employee of a company with at least 3 employees.
Please specify Employee Type:  W2 Employee  or 1099 (Contractor)
Enter Any Notes that might help:
Name of Employer:    
Address of Employer:
City, State & Zip:        
Phone number of Employee:

2 *$60 apx   N/A $2,400 $2,800 Must choose a Critical Illness or Junior Estate Builder benefit also
3   *$161.80 N/A $3,000 $5,000 Both spouses must be covered. Couple Rate Shown. 1st & 15th Effective dates
4   *$114.00 N/A $1,450 $2,900 Both spouses must be covered (Eligible Hospitalizations plus C-Sections Only)

What date would you like the plans to start? (mm/dd/yyyy)  (blank if ASAP, or pick a future date)

* Rates for #3 above: $161.80/month (Or $144.80 for Single Parent plan. 188.80 couple rate if either spouse is over 34, and $266.90 if either spouse is over 44)

* Rates for #34 above are as below:
 
Age Monthly
18-24 $34.43
25-29 $38.84
30-34 $39.89
35-39 $41.78
40-44 $46.04
45-49 $54.71
50-54 $63.33
55-59 $89.92
60-64 $120.88
add $54.55 for each additional child to be covered
Option #4 Above - Example Rate Calculation:
Male Age 24, Female Age 24 (Couple Only Coverage)
$34.43 + $34.43 = $68.86 / month + $34.40/mo
for the 2nd Policy (Wife only needs to be covered)   Total: $103.26 / Month

Male Age 28, Female Age 28 (Couple Only Coverage)
$38.84 + $38.84 = $77.68 / month + $34.40/mo
for the 2nd Policy (Wife only needs to be covered)   Total: $112.08 / Month

Benefit is $725/day x 4 days = $2,900
Remember: These benefits can be used for any medically necessary hospitalization and you can received an additional benefit of up to 10 office visits at $75/visit per couple per year, and an additional 5 office visits at $75/visit

 
Contact Info
Mailing Address
  		 City
 		 State
 Zip
 
Phone   ie (801) 555-1212

Email Address  
Current Health Insurance Plan Information (Required)
Current Health Insurance Company   (ie SelectHealth, Blue Cross Blue Shield, etc)
Current Health Insurance Deductible    (ie $1,000, $500, etc)
Current Health Insurance Policy #  (Important to apply for the plan!)
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		 Smoker?
 No       Yes     

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

Wife State of Birth   (ie: Utah, NY, CA, or Alberta Canada, etc)


Employment  Information - Wife

Hours/wk        (Apx hours per week you work)
Title/Duties:
Employer:      
Hire Date     (Apx)
Time with Company (ie 3 yrs) (Apx)
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 must be covered on Options #2 & #3 - Enter first name only if you are only choosing options #1 and/or #4)
Last Name
 		 First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
 		 Weight (ie 135)
  lbs		 Smoker?
 No       Yes    
Husband Cell Phone   (If any - Not on application, just for contact if underwriting needed)
Last Doctor Visit Information (Husband)

Employment  Information - Husband
Hours/wk       (Apx hours a week you work)
Title/Duties:
Employer:      
Hire Date     (Apx)
Time with Company (ie 3 yrs) (Apx)
 
 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

 Use the following bank information for: 
Bank Name:    
Bank Address
Bank State         Bank City     Bank 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
 

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

Please type in a short summary of the plans you want to apply for
(just to verify) and also any questions/ notes, etc.

  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...

 


AllUtahHealthPlans.com - Contact us at (801) 406-9502
 

blogger statistics

View My Stats