Form 27-B: Health Insurance Card Application Form

Please submit the following forms to initiate the application process.

Name: * Social Security Number: * Mailing Address: * Email: * Pre-Existing Conditions: Diabetes Hypertension Pneumonia * Current Medications: * *

By submitting this form, you acknowledge that you have read and understood the fine print, which includes but not limited to:

• Our health insurance is not actually health insurance.
• You will be audited for any discrepancies.
• We will bill you for everything.
• You will be audited for any discrepancies.

Read the Fine Print (PDF) Read the Disclaimer (Text) View the Insurance Policy (PDF)