Short Term Form

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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 *

Sp. Gender *

C1 Gender *

C2 Gender *

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

Trout Insurance Services

Monday-Friday
8:30am-6pm & by Appointment

Visit: 29 N Main St
Weaverville, NC 28787

Mail: PO Box 1414
Weaverville, NC 28787

Ph: 828.279.4681

Fax: 1.888.221.4842

contact@troutinsurance.com

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