STM-AP-160-GRI-24R 932E-G-1116
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*%9932E-G-1116*
MISSOURI
APPLICATION FOR SHORT TERM MEDICAL INSURANCE
GOLDEN RULE INSURANCE COMPANY — INDIANAPOLIS, INDIANA 46278-1719
Please Print
in Black Ink
*
( )
PROPOSED INSURED
/ /
First Middle Initial Last Height Weight Birth Date Age
Resident Physical Address (where you live and pay taxes).
PO Boxes are not accepted.
Street (Include Apt.) City State ZIP Telephone No.
Mailing Address
(if different than Resident Address)
_________________________________________________________________________________________________________________
Street (Include Apt.) City State ZIP
Email Address _____________________________________________________________________________________________________
Proposed Insured Spouse (if to be covered)
1. List below any dependents to be covered under the policy.
Male
Female
*If born within 30 days prior to the effective date of coverage, the person will not be covered under the policy.
2. Are you or is any family member (whether or not named in this application) an expectant mother or father, in the process of Yes No
adopting a child, or undergoing infertility treatment?......................................................................................................................
If yes, coverage cannot be issued.
3. Have you or has any person named in Question 1 lived in the 50 states of the USA or the District of Columbia for less than
the past 12 months? If yes, state the name of each person: ____________________________________________________
(The person(s) named will not be covered under the policy.)
4. Do you or does any person named in Question 1 now have hospital or medical expense insurance that will not terminate ........
prior to the requested effective date? If yes, state the name of each person: _______________________________________
(The person(s) named will not be covered under the policy.)
5.
Within the last 5 years, have you or has anyone listed on the application 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, 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, state the name of each person: _____________________________________________________________________
(The person(s) named will not be covered under the policy.)
6. Within the last 5 years, have you or has anyone listed on the application received diagnosis or treatment for HIV infection
from a doctor or other licensed clinical professional, or had a positive test for HIV infection performed by a doctor or
other licensed clinical professional? ...............................................................................................................................................
If yes, state the name of each person: _____________________________________________________________________
(The person(s) named will not be covered under the policy.)
7. Have you or has any person named in Question 1 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? ...........................................................
If yes, state the name of each person: _____________________________________________________________________
(The person(s) named will not be covered under the policy.)
Dependent’s Name (Last, First, M.I.) Relationship Height Weight Date of Birth
*
Spouse / /
M
F
/ /
M
F
/ /
M
F
/ /
M
F
/ /
M
F
/ /
M
F
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STM-AP-160-GRI-24R 932E-G-1116
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X
X
X
STATEMENT OF UNDERSTANDING
I have read this application and represent that the information shown on it is true and complete. I understand that: (a) no insurance will become effective
unless my application is approved and the appropriate premium is actually received by Golden Rule with this application; (b) no benets will be paid for a health
condition that exists prior to the date insurance takes effect; and (c) if coverage is issued, the coverage will not be a continuation of any prior coverage.
Incorrect or incomplete information on this application may result in voidance of coverage and claim denial. The information provided in this application, and any
supplement or amendments to it, will be made a part of any policy that may be issued. I understand that for an application sent by any electronic means,
insurance, if approved, will be effective the later of: (i) the requested effective date; or (ii) the day after receipt by Golden Rule. I understand that for a mailed
application, insurance, if approved, will be effective the later of: (i) the requested effective date; or (ii) the day after the postmark date affixed by the U.S. Postal
Service. If mailed and not postmarked by the U.S. Postal Service or if the postmark is not legible, the effective date will be the later of: (i) the requested effective
date; or (ii) the date received by Golden Rule. I understand that the broker is only authorized to submit the application and initial premium and may not change
or waive any right or requirement.
_____________________________________________________________________________ __________________________
Proposed Insured’s Signature or Parent/Legal Guardian if proposed insured is a child Date you signed and read application
___________________________________________ ________________________________ __________________________
Spouse (if to be covered) Licensed Agent or Broker (Please Print) Individual Producer #
Important Notes:
“Postmark date” means the date of the postmark as affixed by the U.S. Postal Service.
• No application will be accepted if received by Golden Rule more than 15 days after the date signed.
Altered applications will not be accepted.
Short Term Medical Plus Elite Short Term Medical Copay Short Term Medical Copay Value
80/20 - $2,000
70/30 - $5,000
Short Term Medical Plus Short Term Medical Value
80/20 - $2,000 70/30 - $5,000
70/30 - $5,000 70/30 - $10,000
DEDUCTIBLE: $1,000 $1,500 $2,500 $5,000 $10,000
MONTHS OF COVERAGE: 1 2 3 4 5 6
OPTIONAL BENEFITS:
Supplemental Accident Benet
$1,000
$1,500
$2,500
$5,000
$10,000
Per Cause Deductible
PRESCRIPTION DRUGS - Select one option:
Prescription Drug - 4 Tier (Available with Short Term Medical Copay Plan only)
Prescription Drug - Discount Card Only (Available with Short Term Medical Copay Plan only)
Prescription Drug - Add Coverage (Available with Short Term Medical Copay Value Plan only)
Prescription Drug - Generic $20 Copay (Available with all Plans except Short Term Medical Value)
REQUESTED
EFFECTIVE DATE:
______/______/_______
(See Statement of Understanding
section.)
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PAYMENT OPTIONS: SINGLE OR MONTHLY (Initial Payment Method Required With Application)
Electronic Funds Transfer (EFT) and Credit Card payment will be collected on the date we issue coverage, or the effective date of the policy, whichever is later.
If coverage is not issued, we will collect EFT or Credit Card payment for the nonrefundable application fee on the date of our decision.
Payor: ____________________________________________________________________________________________________________________
Name Email Address
__________________________________________________________________________________________________________________________
Street City State ZIP
____________________________________________
Contact Number
PAYOR INFORMATION (If other than Proposed Insured)
( )
CREDIT CARD AUTHORIZATION — COMPLETE ONLY IF PAYING BY CREDIT CARD
Credit Card Authorization Visa MasterCard American Express
I authorize Golden Rule Insurance Company to charge my Visa/MasterCard/American Express account for the Single Payment or Monthly Payment above.
_____/______/______ X ___________________________________
Account No. Expiration Date Billing ZIP Code Signature of Authorized User
NOTE: Some card issuers/financial institutions charge cash advance fees on insurance payments. Charge On __________________
(29th, 30th, 31st not available)
Day
ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION — COMPLETE ONLY IF PAYING BY EFT
I (we) hereby authorize Golden Rule to initiate
debit entries to the account indicated below.
I also authorize the named financial institution
to debit the same to such account.
I agree this authorization will remain in effect
until you actually receive written notification of
its termination from me.
Type of Account: Checking Savings
Nine-digit Routing No.
Account No.
Financial Institution’s Name _____________________________________
Address _____________________________________________________
City, State, ZIP ________________________________________________
Draft On _________________________ ________________________
Day Date Signed
X __________________________________________________________
Authorized Account Signature
In Tennessee and Texas, drafts may only be scheduled on 1) the premium
due date; or 2) up to 10 days after the due date.
/ /
Single Payment (one single payment for all months of coverage chosen):
EFT $ Amount ___________ Includes $20 nonrefundable application fee.
Please complete the EFT Authorization below.
Credit card $ Amount ___________ Includes $20 nonrefundable application fee.
Please complete the Credit Card Authorization below.
Check or money order $ Amount ___________ Includes $20 nonrefundable application fee.
Please mail your check or money order, payable to Golden Rule Insurance Company, with your application. Checks are deposited upon receipt.
OR ————————————————————————————————————————————————————————
Monthly Payment:
Initial Payment EFT (Ongoing payment must be EFT.) Credit Card Check or money order
Please mail your check or money order, payable to Golden Rule Insurance Company, with your application. Checks are deposited upon receipt.
$ Amount ___________ Initial Payment amount (shown) includes a one-time $20 nonrefundable application fee.
Ongoing Payments (Choose one)
Direct Bill ($10 monthly billing fee.)
Ongoing monthly Direct Bill payments will not include the $20 application fee, however they will include a $10 monthly billing fee.
Electronic Funds Transfer (EFT) (No billing fee.)
Ongoing monthly EFT payments will not include the $20 application fee.
Credit Card (No billing fee.)
Ongoing monthly Credit Card payments will not include the $20 application fee.
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CONSENT TO RECEIVE ELECTRONIC RECORDS
AND TO CONDUCT TRANSACTIONS ELECTRONICALLY
By submitting this consent form or a health insurance application or HMO enrollment form, you hereby consent
to presentation, delivery, storage retrieval and transmission of “Communications” related to “Our Transaction as
electronic records instead of in paper form.
For the purposes of this form, “Our Transaction means the entirety of the business relationship between you and
us. “Communications” includes, but is not limited to:
1. Your application or enrollment form, including subsequent amendments;
2. Information related to Our Transaction that we are required to provide or make available in writing such as
privacy notices or fraud warnings;
3. Documents related to Our Transaction such as policy, certicate, or evidence of coverage forms, claim
forms, explanation of benet forms, premium notices, or other administrative forms (to the extent permitted
by applicable law);
4. Any emails, faxes, recorded telephone calls, or other electronic transmissions of information between you
and us and an insurance producer contracted with us, or between us and any third party.
Subject to our obligations to protect your privacy, we may, at our sole discretion, post Communications on a
website (in which case they will be sent or received, as the case may be, regardless of whether or not we own,
operate or control the website). Or send them in or attached to an email. You must promptly tell us about any
change to your electronic or physical mailing address, or other contact information.
You acknowledge that you can receive or access Communications because you have the following:
A telephone
A computer and printer
A device or computer program for listening to audio CDs, mp3, WAV or other common computer audio les
An Internet browser
Access to the Internet
A valid email address
Adobe Acrobat Reader or other sufficient PDF reader
You can request a free copy of any Communications, or withdraw your consent to receive electronic
Communications at any time by sending a written request to:
Policy Administration
PO Box 31372
Salt Lake City, UT 84131-0372
I hereby consent to receive Communications and Transaction Documents electronically, as per the
aforementioned conditions. All of the Communications between the time you submit your consent and
withdraw your consent will remain valid and binding on both you and us notwithstanding your withdrawal.
I hereby DO NOT consent to receive Communications and Transaction Documents electronically,
as per the aforementioned conditions. If you do not consent, we will conduct all future business with you
in paper form.
X _____________________________________________ X _____________________________________________
Primary Applicant (You) Parent/Guardian (if you are a minor) Relationship
_____________________________________________ X _____________________________________________
Primary Applicant (You) Email Address Parent/Guardian (if you are a minor) Email Address
_____________________________________________
Date
Aug 25 2016 02:30:46 pm