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Fill out the following so we can pass it on to an insurance agent in
your area.
They will help you get all the information you need to help you with an
upcoming maternity situation!
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Please note: Obviously fake information will be
disregarded, so don't waste your time or ours if you don't put your
real information
as we verify all info before passing it along to the
busy agents that are waiting to help you make a
decision :) |
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Please fill out the following contact information
(for BOTH Spouses)
(Needed by some of the insurance agents to get you the right benefit information for your area and
situation)
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How'd you find us? |
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How can we help? |
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Last Name |
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* (of
wife if it is different than husband's) |
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Husband First Name |
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* Age
* Some
options require both husband & wife to apply if married :) |
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Husband Occupation |
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* |
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Wife First Name |
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Age
* |
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Wife
Occupation |
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Mailing Street Address |
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City |
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Resident State |
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* Choose Utah, Arizona, Idaho, Nevada, or
"Other" if it is not one of those states listed |
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Zip Code |
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* |
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Dual Resident of another State? |
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YES - If so,
which State(s)?
example: You also own a home in another state, family
lives there, or you have residency there (ie in this state now due to
school, etc.) |
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NO - I have no residency situation in
a state other than my current address above |
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If YES is selected above, please explain your
residency situation in the other State: |
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Email Address |
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*
Fake
contact emails will cause info to be discarded :) |
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Best Contact Phone (Home) |
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*
Required to verify
your needs to get you the information you need |
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Wife Cell |
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Husband Cell |
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Current Health Plan(s) |
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Deductible? |
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Does it Cover Maternity? |
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YES - If yes, What is the
Separate Maternity Deductible?
if
known or applicable |
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NO - my insurance plan does not cover
Maternity |
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UNSURE - I am not sure if it covers
maternity |
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Business Ownership
Details - If not a
business owner, skip to next section.
This following section is VERY important!
There are some benefits that depend on employment situations. Please
fill in accurately! |
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We are owners a business: |
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YES - We own our own business |
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Including ourselves, we employ
W2 Employees
and
non W2 employees (1099
etc) |
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Please describe nature of business
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YES - We have a Group
Health Insurance option that we offer at our company |
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NO - We DO NOT offer /
have Group Health Insurance at my company |
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Or... |
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We purchase our own private Health Insurance plan
through
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Employee Information (If
not a Business Owner)
This following section is VERY important!
There are some benefits that depend on employment situations. Please
fill in accurately! |
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Husband Employed at a job. |
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YES - Husband is employed at a company, or has
an employer |
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At Husband's work, there are apx
employees
who work there |
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OR... |
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NO - Husband is not employed, is a student or
otherwise not associated with an employer |
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Wife Employed at a job. |
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YES - Husband is employed at a company, or has
an employer |
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At Husband's work, there are apx
employees
who work there |
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OR... |
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NO - Husband is not employed, is a student or
otherwise not associated with an employer |
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Previous Maternity Delivery
Information please
answer the following to help us understand you past delivery situations.
For example, we have some options that only work if you are going to
have a C-Section. |
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# of Children currently |
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Some of the plans offered require that all your current children must
also be covered to get the benefit |
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Past Maternity Information: |
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Never delivered before, so don't know :) |
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Normal Delivery (You have delivered before, and had a
vaginal delivery or expect to next time) |
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C-Section (You have had C-Sections in the past and/or
expect to have a future C-Section) |
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Please Click Below to verify that you
understand the following:
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I am NOT Pregnant now and understand that some plans have a 10 month
waiting period from the effective date of the policy before I can
get pregnant (Deliver in month 11 or beyond) |
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Enter Questions or Comments Below,
then Submit Button at bottom of page |
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Click Here to Submit >
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