Please Check All That Apply:
What type of
coverage do you want?__Individual
__Individual+ Spouse __Individual+
Child(ren) __Full Family
Date of Birth:
Number of Children ____
Gender: M or F Age or DOB:
Does anyone use Tobacco
products of any kind?______
Does anyone to be covered have
any medical conditions (please list)?______________________________________________________________________________________
Does anyone take prescriptions
Home zip code:
Deductibles Choices with
Co-Pays an Rx: ($500 / $1,000 / $1,500 / $2,500 or $5,000)
HSA Qualified Plans:
____Individual Deductible or ___ Family Deductible
**Maternity is not available.
Newborns must be 14 days old to be added.
Coverage can be Denied, Rated
or Ridered due to Medical Conditions.********************
**Do not cancel any current
health plan before approval with this new one. *******
Did you know we can save you
money on your life insurance too?
Ask me about this.
Send to Richard
Phillippe at fax: 214/696-3322 or RP@rpstrategygroup.com.
Phone us with questions 214/696-4411 ext 302