Individual/Family Plan Enrollment Form

Your Information

Referring Agent *

Start Date * 🛈 +

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

DOB *

Soc. Sec. Number *

Cell Phone Number *

Email Address *

Signature (Print Only, SOF) First Name, Last Name *

After submitting, you will receive a confirmation email

Your Health Plan Type - Choose Your Health Plan, Dental Plan, and Vision Plan. *Choose N/A for services you do need.

iEverydayCare with Hospitalization - Choose Oldest in Plan

Member Only Plans

Member ONLY Plan *

Age 18-44

Age 45-59

Age 60-64

N/A

Delta Dental - Member Only *

Essential Advantage PPO Member - $22.93/mo

Superior Advantage PPO Member - $34.13/mo

Brighter Advantage PPO Member - $37.47/mo

N/A

Delta Vision - Member ONLY *

150 VSP Vision Package - $8.14

175 VSP Vision Package - $11.73

N/A

Member +Spouse

Member +Spouse *

Age 18-44

Age 45-59

Age 60-64

N/A

Delta Dental - Member +Spouse *

Essential Advantage PPO Plus One - $42.99/mo

Superior Advantage PPO Plus One - $64.32/mo

Brighter Advantage PPO Plus One - $71.35/mo

N/A

Delta Vision - Member +Spouse *

150 VSP Vision Package - $16.28

175 VSP Vision Package - $23.46

N/A

Member +Child)ren)

Member +Child(ren) *

Age 18-44

Age 45-59

Age 60-64

N/A

Delta Dental - Member +Child(ren) *

Essential Advantage PPO Family - $79.31/mo

Superior Advantage PPO Family - $100.92/mo

Brighter Advantage PPO Family - $122.40/mo

N/A

Delta Vision - Member +Child(ren) *

150 VSP Vision Package - $26.21

175 VSP Vision Package - $37.77

N/A

Member +Family

Member +Family *

Age

N/A

Delta Dental - Member +Family *

Essential Advantage PPO Family - $79.31/mo

Superior Advantage PPO Family - $100.92/mo

Brighter Advantage PPO Family - $122.40/mo

N/A

Delta Vision - Member +Child(ren) *

150 VSP Vision Package - $26.21

175 VSP Vision Package - $37.77

N/A

Tobacco - Non-Tabacco

Tobacco *

Yes

No

Monthly Premium:

$0.00

List your dependents if applicable.

Spouse

Soc #

Date of Birth +

Dependent 1

Soc #

Date of Birth +

Dependent 2

Soc #

Date of Birth +

Dependent 3

Soc #

Date of Birth +

Dependent 4

Soc #

Date of Birth +

Dependent 5

Soc #

Date of Birth +

How Pre-Existing Conditions are Shared

A condition is considered pre-existing for a member or dependent if symptoms or treatment have occurred within the 12 months prior to joining the Medical Cost Share. See the Membership Guidelines for a detailed description of what will be considered a pre-existing condition. Controlled diabetes, hypertension, high cholesterol, seasonal allergies, and intermittent asthma will not be considered pre-existing when reported prior to the membership effective date.

Conditions beginning after a member’s effective date will be shared after paying their $2,000 initial member responsibility than 20% with a maximum out-of-pocket of $4,000 per year. See the Membership Guidelines for sharing rules.

Additional Sharing Restrictions

See Member Guidelines for detailed shareable restrictions.

Pre-existing conditions become eligible for sharing based on members’ tenure with the plan, as indicated by the following graduated sharing schedule:

Time After Membership - Effective Date. Shareable

First 12 months Not shareable

Months 13-24 Shareable to $25,000

Months 25-36 Shareable to $50,000

Month 37 and after Shareable to $125,000

Get a United Healthcare Critical Illness Quote
to help offset out-of-pocket expenses *

Yes

No

Get a United Healthcare Accident Quote
to help offset out-of-pocket expenses *

Yes

No

Billing Address

Same as Delivery Address

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Payment

Debit/Credit Card Type *

Name on Card *

Credit Card Number *

Expiration Date *

CVV Code *