Hospital Indemnity Enroll

Hospital Indemnity Enrollment Request

Welcome to the enrollment request page. I personally look at each enrollment request and will contact you for the steps necessary to complete the enrollment. Each company have their own procedures for enrollment. Once you submit the information, allow me between 24 and 48 business hours to response (does not include weekend and holidays). Feel free to also Contact me if you have questions.

Please Note: I am a licensed Agent in Colorado only. You must be a resident of Colorado to request an enrollment. However, I am looking into getting licenses in other states in the future. If you like what you see in my website and would like me to expand to your states, send me a request.

Start Enrollment Request

Qualifications

Are you resident of the State of Colorado *

Is your age between 64 years and 6 months old (64 ½ years old) and 65 years and 6 months (65 ½ years old)? *

If you can answer YES, you Get Guarantee issue and does not need to answer Medical Questions

How old are you? *

Medical Questions - If any answer to questions 1 thru 5 is Checked ("YES") you are not eligible for coverage *

1. In the past 12 months have you been confined as an inpatient to a hospital, nursing home or received home health care?
2. In the past 12 months have you had a heart attack, stroke, heart surgery/bypass, malignant melanoma or cancer (other than skin cancer)?
3. In the past 12 months have you had been treated for Chronic Obstructive Lung Disease, insulin dependent diabetes, dementia, Alzheimer’s disease, congestive heart failure, or chronic liver or kidney disease?
4. In the past 12 months have you had surgery which required an inpatient hospital stay or been advised to have surgery which will require an in-patient stay but have not yet done so?
5. Have you ever been treated for or been diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or HIV infection?
None of the above conditions apply to me.

How much Daily Hospital Confinement benefit do wish to buy? *

In addition to DAILY HOSPITAL CONFINEMENT, are you interested in additional riders (Cancer, Ambulance, Outpatient Surgery and/or Skilled Nursing Facility)? *

What other riders are you interested to receive a quote? *

AMBULANCE TRIPS
CANCER
OUTPATIENT SURGERY
SKILLED NURSING FACILITY

Additional Medical Questions for Cancer - If question 6 or 7 is Checked (“YES”), you are not eligible for the Cancer Rider *

6. In the past 10 years, have you had, been diagnosed as having, received medication for, or been treated by a medical practitioner for leukemia, Hodgkin’s or Non-Hodgkin’s disease, malignant melanoma, sarcoma or any other internal cancer or had radiation or chemotherapy for any of these conditions?
7. In the past 24 months, have you been advised to seek treatment or medical advice from a medical practitioner, or had experienced any symptoms that would have caused an ordinarily prudent person to seek medical advice for any of the medical conditions listed in question #6?
None of the above apply to me.

How much Lump Sum Cancer Benefit do you wish to buy? *

$2,500
$5,000
$7,500
$10,000

How much Outpatient Surgery Benefit do you wish to buy? *

$250
$500
$750
$1,000

Email *

Effective Date - Date you would like the policy to start. You can pick any day from today to up to 3 months from today. *

Name *

First

Middle

Last

Gender *

Male
Female

Birth Date *

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Primary Beneficiary - who gets the money if you are not available? *

First

Last

Primary Beneficiary Relationship *

If you are accepted on this plan, will this policy replace any existing insurance you have with any company? *

What company, type(s) of insurance and policy number(s)? *

How often would you want to pay the premiums? *

Monthly - You must use automatic bank withdraw and provide your bank information.
Quarterly - You must write a check for the first payment. The company will send you a bill in the mail for subsequent payments.

Bank Name *

Bank Routing # *

Bank Account # *

Bank Account Type *