• Application for Max Savings, Choice and Choice Plus Plans

Please note: TruAssure cannot accept applications for individual insurance plans via fax or email. All applications must be mailed to TruAssure at the following address: TruAssure, Consumer Direct – Individual, P.O. Box 85418 Chicago, IL 60689-5418.

• Notice to Applicant Regarding Replacement of Accident and Sickness Insurance for Max Savings, Choice, Choice Plus, Basic, Preferred and Preventive Plans

Español

• Solicitud para los planes Max Savings, Choice y Choice Plus

Por favor, note: TruAssure no puede aceptar solicitudes de planes de seguro individual por fax o correo electrónico. Todas las solicitudes deben ser enviadas a TruAssure a la siguiente dirección: TruAssure, Consumer Direct – Individual, P.O. Box 85418 Chicago, IL 60689-5418.

• Group Application with Supplemental Form

• Group Member Enrollment Form

• Group Member Enrollment Form (Español)

• Claim Form

• International Claim Form | International Claims Instructions

• Claims Appeal Procedures

• TruAssure Payment Authorization

• HIPAA Notice of Privacy Practice and Rights

• Authorization for Release of Information

To complete with a digital signature and send electronically, please download this form with Adobe or another PDF reader.

• Authorization for Release of Information (Español)

Para completar con una firma digital y enviar electrónicamente, por favor descargue esta forma por el Adobe u otro lector PDF.

• Privacy Notice (Gramm-Leach-Bliley)

• Non-Discrimination Notice

• Non-Discrimination Notice (Español)