Answer a few questions to see your rate options.
Complete an application with health history.
Submit one month's premium with your application.
Required fields are marked with a red asterisk. *
We've checked the applicant box for you. Check boxes for family members applying with you. If you're applying for someone else, see help on the right.
Applicant
Spouse/Same Gender Domestic Partner
Dependents
(mm/dd/yyyy)
Has your spouse/same sex domestic partner used tobacco and/or smokeless tobacco during the past 24 months? *
Yes No
NOTE: Tobacco-free rates are available only to persons who have not used tobacco and/or smokeless tobacco in the preceding 24 months.
Children under 90 days old are not eligible for coverage, and children age 25 and older must submit their own application.
If applicant is under 18 years old then sibling dependents must be more than 90 days old and less than 18 years old.
Your coverage will begin the day after we receive your application, unless you choose a later date.
I want my coverage to begin on *
Are you a resident of the state of Minnesota?
Coverage for substance abuse is included in the contract. You may choose to delete substance abuse coverage. Your premium will be slightly reduced if you exclude substance abuse coverage.
If you have questions about substance abuse coverage, you can find more information in our help center.
Check this box to EXCLUDE substance abuse coverage
Have you used tobacco and/or smokeless tobacco during the past 24 months?
If you're applying for your spouse or a dependent, but are not including yourself in the application, do not check "spouse" or "dependents." The person you're applying for is the "applicant" (already checked).
RONALD GRAMS JR New Hope, MN 763-550-0638