Vital Health — Find Your Health Plan

SECTION A

Primary Applicant

Enter details for the primary person applying for coverage.

First Name *

Middle Initial

Last Name *

Gender *

Social Security # *

Date of Birth *

Birth Place

Height

Weight (lbs)

Employer

Occupation

Tobacco: Any tobacco or cessation products in the past 12 months?

Resident Address

Street Address *

City *

State *

ZIP *

Home Phone

Cell Phone

Business Phone

Email *

Best Time to Call

SECTION B

Spouse / Partner

Complete if a spouse or partner will be covered. Leave blank if not applicable.

ℹ️ Leave blank and click Continue if no spouse.

First Name

Last Name

Gender

SSN

Date of Birth

Birth Place

Height

Weight

Employer

Occupation

Tobacco: Any tobacco or cessation products in past 12 months?

SECTION C

Dependents

List children or other dependents to be covered (up to 6).

ℹ️ Leave blank and click Continue if no dependents.

SECTION D

Current & Prior Coverage

Answer the following questions about existing health insurance.

1. Does any applicant currently have or has applied for any type of health insurance?

2. Are all applicants covered under prior coverage?

3. Is this coverage intended to replace your existing coverage?

4. Has any applicant ever been declined, had coverage excluded, been charged extra premium, postponed for any insurance, filed a disability claim in past 18 months, or receiving Social Security or Workers’ Compensation?

SECTION E

Prescriptions

List all drugs prescribed or taken by any applicant in the past 12 months.

ℹ️ Leave blank if no prescriptions.

Applicant

Medication / RX

Reason

Doctor

SECTION F

Health Conditions

Has any applicant been diagnosed or treated for any of the following?

SECTION G

Additional Medical Questions

Answer Yes or No. Provide details below for any Yes answers.

Details for any “Yes” answers (Applicant • Question • Condition • Dates • Doctor)

SECTION H

Payment Authorization

Authorize premium collection for your selected health plan.

⚠️ Coverage is not effective until a Policy is issued and first premium is paid.

Requested Effective Date

Monthly Premium ($)

💳 Credit Card — Initial

🏦 Bank Draft — Renewals

Credit Card (Initial Payment Only)

Visa

Mastercard

Amex

Discover

Card Number

Expiration (MM/YY)

First

Last

Billing Address

Bank Draft — Renewal Payments

Bank Name

Bank Address

Routing #

Account #

Check #

Account Holder (if different)

SECTION I

Agent Information & E-Signature

Agent details and applicant acknowledgment.

Agent Information

Agent Name (Print)

Agent Number

Applicant E-Signature

⚠️

By submitting, I certify all answers are true and complete. Misrepresentation may void coverage. I authorize verification of all information. Coverage is not bound until a policy is issued and first premium paid. This e-signature has the same legal force as a handwritten signature (E-SIGN Act).

Primary Applicant Full Legal Name *

Date *

Spouse Signature (if applicable)

Date

✅

Application Submitted!

Your health insurance application has been received. A licensed agent will review your information and contact you within 1–2 business days to confirm eligibility.

Application Reference Number

VH-2025-000000

✓

Confirmation sent to your email. Do not cancel existing coverage until you receive and review your new policy.

Step 1 of 9

Enroll in this plan

You’re all set!

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