Health Plan - thechurchplans.org

In order to provide you with a quote, we need the following information. A licensed agent can be reached to help you through the process, if needed.

Affordable Choice Application

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– Step 1 of 11

Policy Information

Application Type *

New Application
Reinstatement
Benefit Increase

What is your Group Number? *

Applicant's Information

Prefix *

First Name *

Middle Name *

Last Name *

Suffix

Date of Birth *

Height *

Measured in feet and inches

Weight *

Measured in pounds,

Gender *

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

(XXX) XXX-XXXX

Email *

Confirm Email

Social Security # *

Employer Information

Primary Employer *

(Company / Church Name)

Occupation *

Primary Employer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Requested Effective Date *

Physician Information

Information about your primary care provider

Primary Physician's Name *

First and Last Name (and Suffix if needed).

Primary Physician's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Physician's Phone *

(XXX) XXX-XXXX

Insurance Plans

Hospital Indemnity Policy (AFC) [GAPJ15] *

Platinum Elite
Diamond Elite Plus
Silver Classic
Gold Classic Plus

Please select the appropriate plan.

Coverage Applied For: *

Number of Dependents: *

Please select the number of dependents you have. If you do not have any dependents, select None.

Spouse

Spouse – First Name *

Spouse – Middle Name

Spouse – Maiden Name

Spouse – Last Name *

Spouse – Suffix

Spouse – Social Security Number *

Spouse – Gender

Male
Female

Spouse – Date of Birth *

Spouse – Height *

Measured in feet and inches.

Spouse – Weight *

Measured in pounds.

Dependents

Dependent 1 – First Name *

Dependent 1 – Middle Name *

Dependent 1 – Last Name *

Dependent 1 – Suffix

Dependent 1 – Social Security Number *

Dependent 1 – Gender

Male
Female

Dependent 1 – Date of Birth *

Dependent 1 – Height *

Measured in feet and inches.

Dependent 1 – Weight *

Measured in pounds.

Dependent 2

Dependent 2 – First Name *

Dependent 2 – Middle Name *

Dependent 2 – Last Name *

Dependent 2 – Suffix

Dependent 2 – Social Security Number *

Dependent 2 – Gender

Male
Female

Dependent 2 – Date of Birth

Dependent 2 – Height *

Measured in feet and inches.

Dependent 2 – Weight *

Measured in pounds.

Dependent 3

Dependent 3 – First Name *

Dependent 3 – Middle Name *

Dependent 3 – Last Name *

Dependent 3 – Suffix

Dependent 3 – Social Security Number *

Dependent 3 – Gender

Male
Female

Dependent 3 – Date of Birth *

Dependent 3 – Height *

Measured in height and inches.

Dependent 3 – Weight *

Measured in pounds.

Dependent 4

Dependent 4 – First Name *

Dependent 4 – Middle Name *

Dependent 4 – Last Name *

Dependent 4 – Suffix

Dependent 4 – Social Security Number *

Dependent 4 – Gender *

Male
Female

Dependent 4 – Date of Birth *

Dependent 4 – Height *

Measured in feet and inches.

Dependent 4 – Weight *

Measured in pounds.

Additional Dependents

If you have 5 or more dependents, please fill in the first, middle, last name (and suffix, if applicable), social security number, gender, date of birth, height, and weight, for each additional dependent in the block below.

Additional Dependents' Information

Existing Coverage(s) / Replacement(s) / Eligibility

1. Do all members to be insured reside in the home of the applicant? *

Please provide details below: *

2. Has any applicant been declined for insurance due to health reasons? *

Please provide details below: *

3. Are you or anyone listed on this application pregnant? *

Please provide details below: *

4. Are all applicants citizens of the U.S.? *

(If no, you may still qualify for health insurance if you have eligible immigration status.)

Please provide details below: *

5. Is the policy intended to replace any other insurance now in force? *

Please provide company name, policy number, and type of coverage below: *

Health Questions

Dependent following to

1. Has any person proposed for insurance had surgery within the last 5 years? *

Please provide details (date, reasons, results) below: *

2. Has any person had surgery advised but not yet performed? *

Please provide details: *

3. Has any person proposed for insurance been seen within the last 12 months by a physician? *

Please list the person(s), types of treatment, including medication and date last seen by a physician: *

3a. Please list all prescribed medications taken in the last 12 months, condition taken for, and dosage for each proposed insured: *

If nobody on the application has taken a prescription medication in the last 12 months, please respond with N/A..

4. Has any person proposed for insurance been diagnosed or been treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), “AIDS” related complex (ARC), or “AIDS” related conditions, or tested positive for Human Immunodeficiency virus (HIV) or its antibodies? *

5. To the best of your knowledge and belief, in the last 10 years has any person proposed for insurance now have or had cancer in any form including, carcinoma in situ? *

6. To the best of your knowledge and belief, within the last 12 months, has any person to be insured had elevated or rising prostate specific-antigen (PSA) or carcinoembryonic antigen (CEA) test, abnormal mammogram, abnormal pap smear, or abnormal biopsy? *

7. To the best of your knowledge and belief, within the last 12 months, has any person to be insured, received treatment or had tests performed where the results were other than normal or still pending or received treatment for any abnormal tests? *

8. Within the past five years, has any person proposed for insurance been diagnosed (or treated) as having or been told by a doctor that they had any of the following conditions? (Select all that apply.) *

a. Addison’s Disease
b. AIDS, or tested positive for antibodies to the AIDS virus or HIV virus
c. Alcoholism, Alcohol, Chemical Dependency, or Drug or Alcohol Abuse
d. Autism Spectrum Disorders, Autism, Asperger’s Disorder, Rett’s Syndrome, Pervasive Develpmental disorders, or Pervasive Developmental Delay
e. Cancer or Tumor
f. Cataracts uncorrected
g. Cerebral Palsy
h. Liver Disorders, excluding fully recovered Hepatitis A
i. Coronary Bypass
j. Crohn’s Disease or Ulcerative Colitis
k. Currently (or within 3 months) hospitalized or confined to any health care institution
l. Emphysema, Chronic Obstructive Pulmonary Disease, Fibrotic Lung Disease, or Pulmonary Hypertension
m. Diabetes treated with insulin
n. Functionally limiting musculoskeletal disease or disorder
o. Grand Mal Epilepsy
p. Heart Attack
q. Heart Disease
r. Heart abnormality
s. Hemophilia
t. Hernia uncorrected
u. Hepatitis (other than Virus A)
v. Hodgkin’s Disease
w. Kidney disorders, excluding kidney stones
x. Leukemia
y. Mental or Nervous Disorder or disease or disorder of the Central Nervous System
z. Multiple Sclerosis
aa. Osteomyelitis
bb. Paralysis
cc. Peripheral Vascular Disease or
Peripheral Arterial Disease
dd. Rheumatoid Arthritis (requiring 2 or more medications)
ee. Ulcerative Colitis
ff. Sickle cell anemia
gg. Stroke or Brain Aneurysm
hh. Tuberculosis

Did you select any of the checkboxes on Question 8? *

Please provide details for any conditions that were checked: *

9. Has any person proposed for insurance been treated, within the last twelve months, by a physician for elevated blood pressure? *

Please list the name(s) of the person(s), types of treatment including medication, date last seen by a physician, last blood pressure reading, and how long blood pressure has been under control and date diagnosed: *

Please read and sign this application below.

Louisiana law prohibits genetic testing or questions relating to genetic information from being used by health insurance companies as a condition of obtaining health insurance coverage. I hereby authorize any licensed physician, medical practitioner, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager or other medical facility, insurance or reinsurance company, MIB, Inc. (MIB), Division of Motor Vehicles, the Veterans Administration or other medical or medically related facility, insurance company or other organization, institution or person, that has any records or knowledge of me or my health or having any non-medical information concerning me to give to the Manhattan Life Assurance Company of America (the Company) or its reinsurers, any such information. I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal law governing privacy and confidentiality. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I authorize ManhattanLife Assurance Company of America, or its reinsurers, to make a brief report of my protected health information to MIB, Inc. I understand that I am authorizing the Company to receive my health information, prescription drug usage history and my non-medical information. I understand that prescription drug usage may be used to verify the presence of certain medical conditions and that such history will not be used to decline coverage. These medical conditions will be confirmed by a telephone interview prior to being used in the underwriting process. The released information received by the Company will remain protected by federal and/or state regulations. I understand that the information requested is necessary for evaluation and underwriting of my application for the Policy for which I have applied; to determine eligibility for insurance, risk rating or policy issue determinations; obtain reinsurance; administer claims and determine or fulfill responsibility for coverage and provision of benefits; and to conduct other legally permissible activities that relate to any coverage I have, or have applied for, with the Company. I understand that telephone interviews may be a part of the application process and that any information obtained from such telephone interviews may be used to decline my application for coverage. I understand that failure to provide the authorization to the Company will result in the rejection of the Insurance Policy coverage. I understand that I may revoke this authorization at any time by notifying the Company in writing at their Administrative Office: [10777 Northwest Freeway, Houston, Texas 77092]. I understand that such revocation will not have any effect on actions the Company took prior to their receiving the revocation notice. I understand that this authorization will be valid for twenty-four (24) months from the date signed if used in connection with an application for an insurance policy, reinstatement of an insurance policy, change in policy benefits; or, for the duration of a claim if used for the purpose of collecting information with a claim for benefits under a policy. A photocopy of this authorization will be treated in the same manner as the original. To the best of my knowledge and belief, all of the answers to the questions contained in this application are true and complete, and I understand and agree that: (a) the insurance shall not take effect unless and until the application has been accepted and approved by the Company, the full first premium has been paid, and the policy has been delivered to the applicant; and (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing. I, the undersigned applicant, certify that I have read, or had read to me, the completed application and that I realize that any false statements or misrepresentations therein material to the risk may result in loss of coverage under the policy to which this application is a part. THE EFFECTIVE DATE OF THE POLICY WILL BE THE DATE RECORDED BY THE ADMINISTRATIVE OFFICE. IT IS NOT THE DATE THIS APPLICATION IS SIGNED. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. [LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES].

Please type your name to acknowledge signing this application. *

Date *