Family Members To Be Insured

You can insure any one of the following combinations of family members:
• Single adult
• Couple - you and your spouse
• Family - you, your spouse and one or more children
• Single parent household - parent and one or more children
• Single child
• More than one child

The gender and age of each person is also required.

When enrolling a child and/or children only, enter one of the children in the applicant block. Enter any additional children in the appropriate child blocks. Rate computations for child/children only plans vary by carrier. Some insurance companies have specific rates for youth plans and other insurance companies base rates for children on the age of either the youngest

Name

Phone

Email

Zip Code

County

Please enter age and gender of each person, specify if any full-time student below.