Enrollment

Major Med Question*

Are you and your dependents each presently covered under an individual or group health insurance policy that provides major medical, hospital and surgical coverage?
This is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Individuals that do not have major medical, hospital and surgical coverage are not eligible for a supplemental hospital confinement policy and will not be covered under this policy.

Yes

No

You are not eligible for this supplemental coverage

Name*

First Name * Last Name *

Member ID #

Department*

Email Address*

Address*

‎ ‎ City State Zipcode

Phone

Provide required member details and select desired Daily Hospital Benefit amount. Then choose whether or not you’d like to also cover your spouse.

Member Date of Birth*

Member Gender*

Male

Female

Daily Hospital Benefit Coverage Amount

Add Spouse

Spouse coverage will be equal to member's coverage amount.

Spouse Name*

Spouse First Name * Spouse Last Name *

Spouse Date of Birth*

Spouse Gender*

Male

Female

The rates quoted are based on age as of today. Your premium shown on your bill will reflect your age as of your effective date and may differ from above.

Payment Method

Bank Transfer

Bank Transfer (ACH)

Chasehps Payment

Credit card payment via Chasehps secure servers

Hospital Help Plan

Emergency & Accident

Property & Liability

Personal Insurance