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With the termination of Grandfathered plans and the recent Executive Order regarding Short Term Medical plans, You MAY have options. These plans do NOT cover Pre-existing conditions, are medically underwritten and you may be denied coverage. Copays for doctors and prescriptions are generally NOT covered. HOWEVER–if you qualify–these plans MAY be an effective alternative to ACA Plans. Please complete the confidential fact-finder to get started.
Short Term Fact Finder Application
*
Indicates required field
FIRST NAME
*
Spouse First
*
Child1 First
*
Child 2 First
*
LAST NAME
*
Spouse Last
*
Child1 Last
*
Child 2 Last
*
Gender
*
Male
Female
Male to Femalel
Female to Male
Sp. Gender
*
Male
Female
M/F
F/M
C1 Gender
*
Male
Female
M/F
F/M
C2 Gender
*
Male
Female
Male to Female
Female to Male
Birthday M/D/Y
*
Sp. Birthday
*
C1 Birthdate
*
C2 Birthday
*
Height
*
Sp. Height
*
C1 Height
*
C2 Height
*
Weight
*
Sp. Weight
*
C1 Weight
*
C2 Weight
*
If born within 30 days prior to the effective date of coverage, the person will not be covered under the policy.
Applicants must meet our height and weight guidelines to qualify for coverage.
Address
*
Email
*
City
*
State
*
Zip
*
Phone Number
*
County
*
Application Questions
Has Anyone Had...Medical History Information
Are you or is any family member (whether or not named in this application) an expectant mother or father, in the process of adopting a child, or undergoing infertility treatment?
If yes, coverage cannot be issued.
Within the
last 5 years
has any applicant received medical or surgical consultation, advice, or treatment, including medication for
any of the following:
blood disorders, liver disorders, kidney disorders, chronic obstructive pulmonary disorder (COPD) or emphysema, diabetes, cancer, multiple sclerosis, heart or circulatory system disorders (excluding high blood pressure), Crohn's disease or ulcerative colitis or alcohol or drug abuse or immune system disorders?
If yes, select each person
*
Primary
Spouse
Child 1
Child 2
_____
*
Yes
No
_____
*
Yes
No
Has any applicant had testing performed and has not received results, or been advised by a medical professional to have treatment, testing, or surgery that has not been performed?
(The person(s) named will not be covered under the policy).
If yes, select each person
*
Primary
Spouse
Child 1
Child 2
_____
*
Yes
No
Within the
last 5 years
, has any applicant received treatment, advice, medication, or surgical consultation for Human Immunodeficiency Virus infection from a doctor or other licensed clinical professional, or had a positive test for Human Immunodeficiency Virus infection performed by a doctor or other licensed clinical professional?
If yes, select each person
*
Primary
Spouse
Child 1
Child 2
_____
*
Yes
No
Submit
Coverage
Home & Auto Insurance
Health Insurance 2021
Medicare
AARP - Hartford
Life Insurance
Income Protection
>
Disability Insurance
Long-Term Care
Critical Illness
Annuities
Dental, Vision, Accident
Health Insurance 2020
Employee Benefits
Business Owners
>
Employee Benefits
Group Health Insurance
Commercial Property & Liability
Business Overhead Expense Disability
Disability for Business Owners
Critical Illness
Short Term Health
About Us
Our Story
Dave Trout
>
DT Landing
Jessica Cody
>
JC Landing
Jeremy Sheridan
>
JS Landing
Jennifer Trout
Jan Trout
John Phillips
>
JP Landing
Steve Dillingham
Reviews
Client Center
Client Center
Resources
>
Insurance Partners
Lost Subsidy
2019 Verification-a
Renewal 2020
Privacy Policy
BCBS Online Setup
APTC Income 2021 & Tax Form 1040
Asheville Homesharing
American Rescue Plan
ARP Facts CMS
ARP Unemployment
ARP 2020 Excess Premium Subsidy
Community
Music on Main
Manna Fundraiser
Western Women's Business Center Conference
Mural on Main Street
Expanded Team- Next Generation
Back to School
Weaverology
Blog
Contact Us