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Per the HHS rule governing short term limited duration coverage, short term medical policy purchases are limited to a maximum duration of 90 days. You may be eligible to apply for a new policy after your current policy expires (subject to regulations in certain States).

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Applicants

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Eligibility Questions

Please answer the following medical questions for all individuals, including dependents, applying for coverage

Please be aware that any misstatements and omissions may be a material misrepresentation and a basis for rescission of your coverage. In the event of a rescission; (1) coverage will be void as of the Effective Date; (2) all premiums paid will be refunded; (3) any claims that have been submitted will be denied; (4) if any claims have been paid, the amount of claims paid will be deducted from any premium refund due.

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Please check if you have answered the above questions.

Short Term Medical

ACCEPTANCE AND ACKNOWLEDGEMENT:
I hereby apply for the coverage selected on this application form. I understand that the coverage shall not become effective until this application is accepted by the insurer and the initial premium is paid. I read this application carefully and represent that the information I provided is true, correct and complete. I understand that the insurer relied on my statements and my answers to the medical history questions and it is the basis for determining the issuance or denial of coverage. I understand that any misstatement or omission may result in the denial of benefits and/or the termination of coverage.
I agree and understand that coverage will not become effective for any applicant whose medical history changes prior to that person’s Effective Date such that the applicant’s answer would be “yes” to any of the medical history questions in this application and agree to immediately notify the insurer of any such changes. If such person is the Applicant, I understand that coverage is automatically declined for all persons applying on this application.
I understand that health insurance benefits are excluded for pre-existing conditions and this coverage will not pay benefits for a disease or physical condition that I or another applicant may now have or have had within 5 years of the application for coverage.
I understand that the producer who solicited this application and upon whose explanation of the benefits, limitations or exclusions I relied on was retained by me as my agent and is an independent contractor who has no right to alter the application, bind or approve coverage or alter any of the terms or conditions of the policy.
I understand that cancellation of this coverage within the 10 day right to return the policy period will result in a refund of premiums only. Any administrative fees or other fees that may apply will not be refunded.
I understand that this coverage for which I am applying is not Minimum Essential Coverage as defined by the Affordable Care Act of 2010 (ACA). Even if I have this coverage, I still may be subject to the federal tax assessed against individuals without Minimum Essential Coverage.

AUTHORIZATION TO RELEASE INFORMATION: I authorize any health care provider, doctor, medical professional, medical facility, insurance company, pharmacy benefit manager, person or organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability of employment related information concerning the patient, excluding genetic information, to the insurer or its administrator.

Applicants under the age of 18 must have a Parent/Guardian signature
You agree and consent the use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using this website; or in accessing or making any transactions regarding this application constitutes your signature, acceptance, and agreement as if actually signed by you in writing. Further, you agree no certification authority or other third party verification is necessary to the validity of your electronic signature; and the lack of such certification or third party verification will not in any way affect the enforceability of your signature or the resulting contract. You warrant that all the information you have provided is true, complete and accurate.
Please note:
  • Any electronic document bearing a user’s e-signature will be considered "in writing" and "wet-signed".
  • Any user e-signed document shall be deemed to be an “original” document when printed and used in the normal course of business.
  • Absent manifest error, the admissibility, validity, or use of any e-signed electronic document cannot be contested.

Short Term Medical

Fraud Warning:
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading may be guilty of insurance fraud and subject to criminal and/or civil penalty.

Review and Acknowledge

Please verify that you accept and understand the terms and disclaimers below, and complete the electronic signature.

This is the information that we will include on your application to pay your first month’s premium directly to your insurance carrier.
Payment Summary
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify The Loomis Company or its designated administrator in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that The Loomis Company or its designated administrator may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated in this authorization form.
If applicable, premium will be debited immediately following receipt of the form.

Billing Info

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Temporary health insurance is a perfect solution for individuals needing insurance in the short term, whether they are uninsured, unemployed, self-employed or just need an affordable insurance product that fits their monthly budget.
Temporary health insurance is a perfect solution for individuals needing insurance in the short term, whether they are uninsured, unemployed, self-employed or just need an affordable insurance product that fits their monthly budget.

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Disclaimers

  • These products are not qualifying health coverage (“Minimum Essential Coverage”) that satisfies the health coverage requirement of the Affordable Care Act. If you don't have Minimum Essential Coverage, you may owe an additional payment with your taxes.

  • The termination or loss of this policy does not entitle you to a special enrollment period to purchase a health benefit plan that qualifies as minimum essential coverage outside of an open enrollment period. These products may include a pre-existing condition exclusion provision.
  • PLEASE MAKE SURE YOU UNDERSTAND AND AGREE WITH THE TERMS OF THE INSURANCE POLICY. PAY SPECIAL ATTENTION TO THE EFFECTIVE DATE, PREMIUM AMOUNT, BENEFITS, LIMITATIONS, EXCLUSIONS, AND ANY BENEFIT RIDER, IF APPLICABLE.
  • The quote includes premium, monthly fees and a one-time initial enrollment fee. Refunds are not available after your 10-day right to return period as outlined in the first page of your policy.
  • All applications and policy quotes are subject to final approval by our Policy Administration Department prior to issuance. All quotes shown are estimates ONLY. Premium will not change unless effective date changes or the applicant provides updated information prior to policy issuance. If the insured selects an optional benefit, that is included in the quote.
  • The quote shown above is for your requested effective date ONLY. If the actual effective date of your policy is different from the requested effective date, the actual cost of your policy may differ from the quote above.
  • If such a cost variance occurs you will be notified of your actual policy cost by our Policy Administration Department prior to issuance.
  • The application and initial payment must be received by us prior to the requested effective date. If a monthly billing method has been selected, future payments will be due monthly on the billing date.
  • ENROLLMENT AND MONTHLY FEE DISCLOSURE: A one-time enrollment fee is applied to your initial payment. A separate monthly fee is included in the monthly charge. The enrollment and/or monthly fee will not affect your eligibility for coverage.
  • Replacement of any existing policy: This is not an ACA-qualified plan. If you intend to lapse or otherwise terminate existing health insurance and replace it with a policy to be issued by Independence American Insurance Company, please note that the coverage is not Minimum Essential Coverage as defined by the Affordable Care Act of 2010 (ACA). You may still be subject to the federal tax assessed against individuals without Minimum Essential Coverage. We recommend that you read and understand the terms of the Policy carefully including effective date, premium amount, total monthly cost, benefits, limitations, and exclusions.
  • Short Term Medical (STM) is a limited duration medical expense policy and is non-renewable. STM is not a replacement for the comprehensive health insurance required under the ACA. This coverage has a pre-existing condition limitation provision.
  • These plans are not available in all states and availability in a state is subject to change. If you submit an application for a state where the plan is no longer available, your application and premium (if included) will be returned and coverage will not be effective.
  • Pre-Existing Condition Limitation – The short-term limited duration medical expense product does not provide portability of prior coverage. Any injury, sickness for which you have incurred charges, received medical treatment, consulted a health care professional, or taken prescription drugs within 5 years (length depends on state) of the effective date of the policy will not be a covered benefit.
  • Non-Renewable - If you purchase a new policy, any conditions for which you incurred claims under the prior policy is considered a pre-existing condition. The purchase of a new policy is not guaranteed and you may be ineligible for new coverage based on pre-existing conditions. The new policy will have a new deductible and coinsurance limit to be satisfied according to the policy documents.

About the IHC Group:
Independence Holding Company (NYSE: IHC) is a holding company that is principally engaged in underwriting, administering and/or distributing group and individual specialty benefit products, including disability, supplemental health, pet, and group life insurance through its subsidiaries since 1980. The IHC Group owns three insurance companies (Standard Security Life Insurance Company of New York, Madison National Life Insurance Company, Inc. and Independence American Insurance Company), and IHC Specialty Benefits, Inc., a technology-driven insurance sales and marketing company that creates value for insurance producers, carriers and consumers (both individuals and small businesses) through a suite of proprietary tools and products (including ACA plans and small group medical stop-loss). All products are placed with highly rated carriers.

About Independence American Insurance Company:
Independence American Insurance Company is domiciled in Delaware and licensed to write property and/or casualty insurance in all 50 states and the District of Columbia. Its products include short-term medical, hospital indemnity, fixed indemnity limited benefit, group and individual dental, and pet insurance. Independence American is rated A- (Excellent) for financial strength by A.M. Best Company, a widely recognized rating agency that rates insurance companies on their relative financial strength and ability to meet policyholder obligations (an A++ rating from A.M. Best is its highest rating).

This plan is administered by The Loomis Company.

About The Loomis Company

The Loomis Company (Loomis), founded in 1955, has been a leading Third Party Administrator (TPA) since 1978. Loomis has strategically invested in industry leading ERP platforms, and partnered with well-respected companies to enhance and grow product offerings. Loomis supports a wide spectrum of clients from self-funded municipalities, school districts and employer groups, to large fully insured health plans who operate on and off state and federal marketplaces. Through innovation and a progressive business model, Loomis is able to fully support and interface with its clients and carriers to drive maximum efficiencies required in the ever evolving healthcare environment.