Fill out the form below to apply for coverage.

If you have any issues, call 1-855-874-0264, or email insinfo@usiaffinity.com

What state do you reside?
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(Estate unless designated)

Are you actively at work?

(Spouse includes Domestic Partner or Civil Union Partner)
List all eligible children for whom you are proposing coverage
Benefits Plan Option Limits Certificate-year Maximum Number of Covered Days
Benefit Waiting Period for Sickness Per Covered Person 30-days  
Daily Hospital Confinement Benefit $200 $300 $400 $500 365
Daily Intensive Care/Coronary Care $200 $300 $400 $500 365
Paid in lieu of Hospital Yes Yes Yes Yes  
Daily Skilled Nursing $200 $300 $400 $500 30
Daily Emergency Room $200 $300 $400 $500 2
Ambulance $200 $300 $400 $500 2
Please Select Your Plan  
 
Optional
Daily Surgical Benefit
Plan Options Certificate-year Maximum
Number of Covered Days
No Surgical Option   Inpatient Outpatient
$1,000 Surgical Option $1,000 1 1
$2,000 Surgical Option $2,000 1 1
 

Requested Effective Date
Coverage can be requested to become effective for a specified date in the future but cannot be more than 30 days.

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
WARNING: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
WARNING: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

CALIFORNIA LAW PROHIBIS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH INSURANCE COMPANIES AS A CONDITION OF OBTAINING HEALTH INSURANCE COVERAGE.

THE FALSITY OF ANY STATEMENT IN THIS APPLICATION SHALL NOT BAR THE RIGHT TO RECOVERY UNDER THIS POLICY UNLESS SUCH FALSE STATEMENT WAS MADE WITH ACTUAL INTENT TO DECEIVE OR UNLESS IT MATERIALLY AFFECTED EITHER THE ACCEPTANCE OF THE RISK OR THE HAZARD ASSUMED BY THE INSURER.

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. EACH PERSON TO BE INSURED UNDER THIS POLICY MUST ALSO BE COVERED BY AN INDIVIDUAL OR GROUP POLICY OR CONTRACT THAT ARRANGES OR PROVIDES MEDICAL, HOSPITAL, AND SURGICAL COVERAGE NOT DESIGNED TO SUPPLEMENT OTHER PRIVATE OR GOVERNMENTAL PLANS.

Does each person to be insured under this Policy have comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits?

Note: Any person for whom the answer is "No" cannot be covered under this Policy.

WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
WARNING: Any natural person who knowingly or willfully: makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing: (a) in any written statement or certificate; (b) in the filing of a claim; (c) in the making of an application for a policy of insurance; (d) in the receiving of such an application for a policy of insurance; or (e) in the receiving of money for such application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or fraudulent claim or other benefit by an insurer commits the crime of insurance fraud.
WARNING: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

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. EACH PERSON TO BE INSURED UNDER THIS COVERAGE MUST ALSO BE COVERED BY AN INDIVIDUAL OR GROUP POLICY OR CONTRACT THAT ARRANGES OR PROVIDES MINIMUM ESSENTIAL COVERAGE.

Is each person to be insured under this coverage also covered by an individual or group policy or contract that arranges or provides Minimum Essential Coverage?

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of insurance fraud as determined by a court of law.

WARNING

Application: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Claim Form: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime

YOUR RIGHTS REGARDING THE RELEASE AND USE OF GENETIC INFORMATION: In connection with an application for health insurance coverage you or any prospective insured are not required to be the subject of a genetic test or to be subjected to questions relating to genetic information. We have no right to obtain genetic information from you or any prospective insured or from their DNA sample, without first obtaining written informed consent from such person or his representative. Coverage under the Policy cannot be denied, restricted, limited, nonrenewed or terminated solely on the basis of any genetic information.

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.

Are you (and each of your dependents to be insured under this coverage) also covered by an individual or group policy or contact that arranges or provides Minimum Essential Coverage?

WARNING: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice of Information Practices:

Personal information may be collected from a person other than the individual proposed for coverage in order to process claims, such as providers of medical services or supplies covered by the Policy.

Such information as well as other personal or privileged information subsequently collected by the insurance institution or insurance representative may in certain circumstances be disclosed to a third party without authorization in order to process claims submitted under the Policy.

A right of access and correction exists with respect to all personal information collected, including:
(a) the right to obtain personal information collected or maintained by Us and a list of persons to whom information has been disclosed;
(b) the right to have factual errors corrected and misrepresentations amended upon written request; and
(c) the right of the individual to receive the specific reason for an adverse underwriting decision.
Procedures for exercising these rights will be furnished upon request.

WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage.

THE POLICY DOES NOT MEET THE FEDERAL REQUIREMENT TO HAVE HEALTH CARE COVERAGE UNDER THE AFFORDABLE CARE ACT.

REVIEW YOUR CERTIFICATE CAREFULLY.

Will any portion of the premium be paid by or on behalf of a small employer, either directly or through wage adjustments or other means of reimbursement?

Does the applicant or any proposed insured individual intend to treat this coverage as part of a plan or program for the purposes of sections 106, 125 or 162 of the Internal Revenue Code?

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
WARNING: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
WARNING: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Will this insurance replace existing or pending insurance? If Yes, please provide the name of the policyholder, insurance company, policy or application number and effective date of coverage.

THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE: If You or any Dependents covered under this Certificate have received medical care or advice within the past 90 days for a disease or physical condition, You, he or she will not be covered for such disease or physical condition until You, he or she has been covered for 12 months under this Policy. This exclusion, however, only applies to a disease or physical condition for which medical care or advice has been received in the past 90 days.

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 is guilty of insurance fraud.
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

CONSUMER NOTICE:

This is a LIMITED BENEFIT POLICY. It does not cover all of the essential health benefits required by the Affordable Care Act. Depending upon your household income and other personal circumstances, you may be subject to federal penalties after January 1, 2014 unless you are covered under a health insurance plan with essential health benefits.

Do you need help finding affordable health insurance coverage that best fits your health care needs? HealthSource RI, Rhode Island’s health benefits exchange, is a new way for Rhode Islanders to find, compare, and purchase health insurance. You or your family may qualify to receive tax credits to help pay for insurance, to enroll in low-cost or no cost insurance options. To answer your questions, and to help you find a health insurance plan, you can contact the HealthSource RI support team on-line, by phone, in person, or by mail.

  • On-line: visit www.healthsourceri.com
  • By phone: call toll free at 885-574-2843. 7 days a week, Monday - Saturday 8 am - 9 pm, Sunday noon - 6 pm.
  • In person: To find the HealthSource RI office near you, call 885-574-2843 or walk in at 70 Royal Little Drive, Providence, RI 02904.
  • By mail: HealthSource RI, Hazard Building Mailroom, 75 West Road, Ste 500, Cranston, RI 02920

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

WARNING: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
WARNING: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
WARNING: Any person who, with the 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 may have violated state law.

Do you intend for this coverage to replace any other accident and health insurance presently in force?

If yes, describe:

WARNING: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

THE POLICY PAYS LIMITED BENEFITS. READ YOUR POLICY CAREFULLY.

PRE-EXISTING CONDITION LIMITATION

Pre-existing Conditions will not be covered for a period of the first 12 months after the Covered Person’s Effective Date of coverage (applies to Hospital, Surgery and related Anesthesia benefits only).


CERTIFICATION: To the best of my knowledge and belief, the answers to the questions on this Enrollment are true and complete. They are offered to United States Fire Insurance Company as the basis for any insurance issued. I have read the completed enrollment form and I realize any false statement or misrepresentation may result in loss of coverage under the Certificate. I understand and agree that if this enrollment is accepted by the Company, coverage will begin on the date of acceptance, subject to the payment of the required premium.
CERTIFICATION: To the best of my knowledge and belief, the answers to the questions on this Enrollment are true and complete. They are offered to United States Fire Insurance Company as the basis for any insurance issued. I have read the completed enrollment form and I realize any false statement or misrepresentation may result in denial of claims under the Certificate. I understand and agree that if this enrollment is accepted by the Company, coverage will begin on the date of acceptance, subject to the payment of the required premium.
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