Application for Medical Insurance

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Select Your Age Group

*Medical Insurance Coverage decreases 50% after the age of 80 *

Total

$0.00

Monthly Amount

Please state the condition, along with the name and address of the Attending Physician/s:

Physician Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please state beneficiary information:

Beneficiary Name

First

Last

Date of Birth

Relationship

Beneficiary Percentage

A TRUSTEE MUST BE APPOINTED IF CHILDREN UNDER AGE 18 ARE NAMES AS BENEFICIARIES

I hereby apply for membership in National Workers Health Plan for myself and any eligible dependents and authorize my employer to make any deductions, as required as my contribution towards the premium. I hereby certify that the information furnished by me in this application is true and complete to the best of my knowledge and belief. I understand any material omission or misrepresentation may result in termination of enrollment and denial of insurance and will cooperate fully with NWHP to provide information necessary to coordinate benefits.

I authorize any physician, medical practitioner, hospital clinic, other medically-related facility, consumer reporting agency, insurance or reinsurance company or employer having certain information about my spouse, children, or by me to release NWHP or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes information of physical conditions, health histories, avocations, ages, occupations, and personal characteristics. This authorization includes information about drugs, alcoholism, or mental illness. I authorize the compant to release any information obtained to reinsuring companies or other persons or organizations performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as i may further authorize. i agree that a photographic copy of this authorization shall be as valid as the origional.

Employee's Signature

Signature

Clear Signature

Date

Has anyone smoked cigarettes or used tobacco products within the past 12 months?

Answer The Following

Name

First

Last

Physician/ Clinic Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Physician/Clinic Phone Number

Date Seen

Condition/ Diagnosis Treatment/ Medication

Signature

Clear Signature

Date

Custom Captcha

Please state dependents information:

Please state the condition, along with the name and address of the Attending Physician/s:

Please state beneficiary information:

Employee's Signature

EVIDENCE OF INSURABILITY FORM

Health History Questions For Applicant and Dependents

Answer the questions below for all persons proposed for coverage

Who?

Answer The Following