Healthy Adults

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Healthy Adults Enrollment Application - Apply Now!

Please note all new members become active on the 1st of the month following the month they were approved. All applications are subject to underwriting and approval. Not all applicants will be accepted.

Step One: Fill out the following application. Make sure to read and understand the entire application. If you have any questions during this process please feel free to contact our Customer Service Department at 888-429-9776, Monday through Friday between the hours of 8:30 am and 5:00 pm PST.

Step Two: Your application will then be submitted to Healthy Adults for approval. Once approved a copy of you application will be sent you by mail.

Step Three: When you receive the document, please sign and return the application. You will need to provide a payment for your first month’s premium payment, along with a one time $50 application fee. Your application will not be submitted for processing if you do not include the entire amount with your application. ($50.00 plus your first month’s premium payment)

Checks Payable To:
Healthy Adults
100 Oceangate, Suite 700
Long Beach, CA 90802

Step Four: Upon receiving your application and payment, Healthy Adults will process your application. You will then receive your Healthy Adults Welcome Pack along with your insurance ID card the first week of your effective date.

Preferred Language*:

Required Fields (*)

Coverage Type*:

Plan A
Association Benefits

First Name*:

Middle Initial:

Last Name*:

Home Address*:

City*:

State*:

Zip*:

Phone*:

Cell Phone:

Fax:

Occupation:

Employer:

Employer's Address:

Business Phone:

Date of Birth*:

Marital Status:

Single Married

Spouse's Maiden Name:

Spouse First Name:

How Did you Hear About Us*:

Gender*:
Male Female

Height*: FT INCHES Weight*: (Lbs.)

Part Three: Health History

- Include all information
ALL family members you wish to cover. All questions must be answered or this application will be rejected!

Have you or any eligible dependents for whom coverage is requested been eligible or received any health benefits from any provider of benefits exceeding $5,000.00 during the past three years?	Yes No
Have you or any eligible dependent applying for coverage been confined in a hospital or other medical care facility for a period of three consecutive days within the past three (3) years?	Yes No
Are you currently approved on a health care insurance plan?	Yes No
If a female applicant, are you pregnant?	Yes No
If a male applicant, is your eligible dependent spouse pregnant?	Yes No
Are you or your family currently taking any medication? If yes, please provide details below.	Yes No
Have you or any eligible dependants ever had or been treated for acquired immune deficiency syndrome (AIDS), chronic pneumonia, Kaposi’s sarcoma, heart disease, cancer, diabetes, alcoholism or substance abuse or addiction, or stroke?	Yes No
Are you or any eligible dependent applying for coverage been treated for (if answering “yes” to any of these statements, please circle the disorder): Disease of the urinary tract, digestive system, reproductive system, liver, lungs, back, bone or joints? High blood pressure, chest pain, seizures, rheumatic fever, heart murmur, or tuberculosis? Tumor or growth, thyroid disease, paralysis, arthritis, nervous or mental disease or condition? Any other disease or deformity?	Yes No Yes No Yes No Yes No

Please provide details and complete answers to any of the above questions to which you answered "Yes."

NOTICE OF INFORMATION PRACTICES:
If you apply for or are covered by North Carolina Mutual Life Insurance Company, Healthy Adults Benefits Association (or an Association DBA) may collect personal information about you in order to evaluate your application. This information is normally limited to the condition of your health. Under California law this information, under certain circumstances, may be given to others without your specific authorization. For example, Healthy Adults Benefits Association (or an Association DBA) may provide information in order to verify benefits. Upon your request, Healthy Adults Benefits Association (or an Association DBA)will provide details of the nature of personal information that may be collected, the circumstances under which it may be disclosed without authorization, and your right to access and correction if you believe it to be inaccurate. Healthy Adults Benefits Association (or an Association DBA) can choose to furnish the medical record information either directly to you or to a medical professional designated by you.

Part Four: Payment Options

Include all information on ALL family members you wish to cover. All questions must be answered or this application will be rejected!

Effective Date:

Not An Active Application

Monthly Premium Calculation: Submit Application For Premium

Additional Options________________________

Monthly Checking Account Deduction Authorization

In addition to the monthly premium stated above, monthly Transaction Fees will be 3% of the gross premium plus a $0.40 Transaction Fee. Applicant will also be charged a "one time" processing fee from the licensed authorized insurance agent.
Please fill out the information listed below.

Complete this section and attach a blank check marked "Void" to the following page if you want to implement Option Two above (deposit slips not acceptable). If the account listed below is a joint account, both account holders' signatures are required.
AUTHORIZATION: As a convenience to me, I request and authorize you to pay monthly plan premiums on the first of the month in the amount of $___________and charge to my account and payable to the order of Healthy Adults Benefits Association (or an Association DBA), provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such debit shall be the same as if it were check drawn on you and signed personally by me. I authorize Healthy Adults Benefits Association (or an Association DBA) to initiate debits (and/or corrections to previous debits) from my account with the financial institution indicated for payment of Healthy Adults Benefits Association (or an Association DBA) dues.
This authority is to remain in effect until revoked by me in writing, and until you actually receive such notice, I agree that you shall be fully protected in honoring any such debit. I further agree that if any such debit be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of insurance.

Authorized Signature _______________________________Date_____________
(As it appears in financial institution’s records)

Authorized Signature ________________________________Date____________
(As it appears in financial institution’s records)

NOTE: Should your withdrawal not be honored by your bank, you will automatically be removed from Monthly Checking Account Deduction and will be sent monthly payment vouchers for the remainder of your policy period. A certified check or money order will be required to be sent monthly to keep your policy in force. After 12 months, you may re-apply for the Monthly Checking Account Deduction Option. You will incur a $15 service charge for any withdrawal not honored.

>> STAPLE BLANK VOIDED CHECK HERE <<

Part Five: It is important that you carefully read and fully understand the following:

Plan Applicants

If an Applicant does not read English, a Spanish translation of this Application is available. All Applicants age 18 and over must personally read and agree to sign the following.

I, the undersigned, understand that under the Healthy Adults Benefits Association (or an Association DBA) Health Care Plan, in which I am enrolling, I will not be entitled to Covered Benefits if I use a non-contracting a physician I was not assigned to.

I understand I will only receive Covered Benefits for services by or authorized by the Exclusive Provider Primary Care Physician and hospital that is in the network.

IMPORTANT: The effective date of your Healthy Adults Benefits Association (or an Association DBA) policy will be the 1st of the month following approval of your application. Premiums are due First (1) day after the effective date each and every month while coverage is effective. Requesting an effective date does not guarantee underwriting to be completed before the date requested. The term of the subject policy shall be for a duration of 12 months and premiums are based and depend on the appropriate costs associated with providing medical services. As damages are difficult to ascertain for early termination, should an insured terminate the policy prior to the 12 month term expiring, then the insured shall be charged a one time early withdraw fee in the amount of $250.00

Initials___________

Agreement (all applicants)

By applying for Coverage, I, the undersigned, agree to the following:

Healthy Adults Benefits Association (or an Association DBA) may decline my application, and if so, neither I nor any dependents for which coverage is applied for will have any coverage. No coverage comes into effect unless and until Healthy Adults Benefits Association (or an Association DBA) approves my application and informs me in writing. The effective date of my coverage, if this application is accepted, will be assigned at Healthy Adults Benefits Association’s (or an Association DBA’s) discretion.

Even if I pay money with this application, that money is only a deposit against the first premium if this application is accepted. Cashing my check does not mean my application is approved. If this application is declined, neither Healthy Adults Benefits Association (or an Association DBA), nor any affiliated company shall have any liability to me or anyone else listed on the application, except for the obligation to return the deposit submitted with this application. If this application is not accepted, neither I nor anyone listed on the application will be entitled any benefits or coverage from Healthy Adults Benefits Association (or an Association DBA).
The selling agent has no authority to promise me coverage or to modify Healthy Adults Benefits Association (or an Association DBA) Schedule of Benefits coverage.

I have provided everything necessary to be able to assure you that all information listed on this application about myself and my family is true and complete. I understand and agree that each applicant is responsible for the accuracy and completeness of this application. I understand and agree that no one listed on this application will be eligible for coverage if any information is false or incomplete and that Healthy Adults Benefits Association (or an Association DBA) may revoke coverage if it discovers that any information on this application is incomplete or false.

AUTHORIZATION

Authorization to Obtain or Release Medical Information: I authorize any physician or other healthcare professional, hospital or other healthcare facility, counselor, therapist, or any other medical or medically related facility or professional to give Healthy Adults Benefits Association (or an Association DBA) or affiliate agents, employees, designees, or representative, including my Healthy Adults Benefits Association, Agent or Broker, any and all information of records relating to the medical history, medical examinations, services rendered, or treatment given, including treatment for alcohol abuse, substance abuse, mental or emotional disorders, A.I.D.S. (Acquired Immune Deficiency Syndrome), or A.R.C. (AIDS-Related Complex) or any of my dependants applying for or having Healthy Adults Benefits Association (or an Association DBA) coverage. I understand that this information may be collected in connection with the review, investigation or evaluation of any application for coverage, of any claim for benefits, or of any inquiry or grievance. I understand that California law prohibits an HIV test from being required or used as a condition of obtaining medical coverage.

I also authorize Healthy Adults Benefits Association (or an Association DBA) to disclose all such medical or personal information related to myself or any covered dependent, to health care provider, a health care services plan, a self-insurer, or any insurance company for the purpose of investigating, coordinating or evaluating any claim for benefits.

This Authorization is effective immediately and shall remain in effect for a period of thirty (30) months, except that it shall remain effective for use in connection with any claim for benefits for as long as any Healthy Adults Benefits Association (or an Association DBA) coverage may be in effect. A photocopy of this Authorization is as valid as the original, and I, and my Healthy Adults Benefits Association, agent or broker, am entitled to receive a copy of this form.

I have personally read and completed this application. If I am accepted, this application will become part of the contract between Healthy Adults Benefits Association (or an Association DBA) and me. I and any enrolled family members agree to abide by the terms of that contract, including the arbitration provision that provides as follows:

"Any dispute between me, and Healthy Adults Benefits Association (or an Association DBA) and/or North Carolina Mutual Insurance Company, and/or their affiliates must be resolved by binding arbitration in accordance with the rules of the American Arbitration Association before one neutral arbitrator if the amount in dispute exceeds the jurisdictional limits of the Small Claims Court. Any such dispute therefore will not be resolved by lawsuit or court process, except as California law provides for judicial review of arbitration proceedings. Under this coverage, both I and my enrolled family, and Healthy Adults Benefits Association (or an Association DBA), and its affiliates, are giving up the right to have any dispute decided in a court of law or before a jury."

By Signing, the undersigned individual, and his or her family, is applying for enrollment into the Healthy Adults Benefits Association (or an Association DBA). The undersigned hereby acknowledges and agrees that "Healthy Adults" does NOT cover claims for hospitalization including emergency rooom visits.

Signature of Applicant:________________________________ Today’s Date: _________________

Signature of Agent:_________________________ Date__________ Lic. No._______________

Please include below all additional dependents you would like to make eligible for the Healthy Adults Benefits Association non-insurance benefit package:

	Name	Relationship	Date of Birth
1
2
3
4
5
6