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Utah Maternity Application

The following form is sent through secure encryption directly to our secure server.
You will receive an application that will be filled out based on your information below
The form will be emailed to you and will be PASSWORD PROTECTED
using you Zip Code entered as your Password to avoid someone getting your info
by accessing your email.  The email you receive will NOT remind you that your password
is your Zip Code. The Email you receive will have instructions on how to submit it.
Your agent will contact you to go over the following information and explain all the details
Thanks!

Please click on circle buttons CAREFULLY! 
For some reason it is hard to "Unselect" an option after you select it

How'd you find us?     


Please Click next to the Plan(s) you wish to apply for:
You can choose one or both of the options below...

   *   

 # Monthly Rate Couple
Rate		 2 Day
Benefit		 4 Days
Benefit

Application Notes:
 
1 $102.09 N/A $3,145 $4,345 Wife Only Covered
2 Apx $95 * Apx $95 * $2,400 $4,550 Both Spouses must both be covered
Note:  Option #2 above requires that both spouses be covered. Rates are calculated by adding up the following rates below. Smoker rates are higher (see agent):
 

* Option #2 Non-Smoker Rate Calculations
Utah Rates
Female
Ages        Rate
18-24      $61.49
25-29      $65.97
30-34      $63.54
35-39      $61.66
40-44      $65.35
45-49      $74.97
50-54      $90.03		 Male
Ages        Rate
18-24      $26.77
25-29      $29.80
30-34      $35.49
35-39      $43.38
40-44      $54.54
45-49      $70.21
50-54      $91.29

Example:  Female 24, Male 29 = $61.49 + $29.80 = $91.29
See agent for exact rates - Smoker rates are slightly higher
 
Contact Info
Mailing Address
  		 City
 		 State
 Zip
 
Phone    555-1212
 ()  		Email Address
 
 
Wife Info
Last Name
  		First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
  		Weight (ie 135)
  lbs		 Birth State (ie UT))
 Drivers License #
 		 Smoker?
 No       Yes    


Employment  Information

Hours/wk     Title/Duties:
Employer:    Time with Company (ie 3 yrs)
Please Click Below to verify that you understand the following:
I am NOT Pregnant now and understand that no benefits will be paid for delivery within the first 10 months of the plan being in force.
 
Husband Info (Note: Husband is Covered on Option #2 - If you are not choosing Option #2, you don't need the husb info)
Last Name
 		 First Name
 		 Mid Init
 mm /  dd   /   yy
 		 Age
 Social Security #
 
Height (ie 5'6")
 Weight (ie 135)
  lbs		 Birth State (ie UT))
 Drivers License #
 		 Smoker?
 No       Yes    

Employment  Information
Hours/wk    Title/Duties:
Employer:    Time with Company (ie 3 yrs)

 
What date would you like the plans to start? (mm/dd/yyyy)  (blank if ASAP, or pick a future date)
Note: We will try to get the effective date as close to the requested date as possible. Average is 3-5 business days after the application is received. All plans have a 10 month waiting period meaning you have to deliver in month 11 or beyond.
Effective dates can be any date from the 1st to 28th of the month only.  Although these supplemental policies can be used for maternity hospitalizations, remember that you can use this policy for any covered hospitalization that is medically necessary (see contract for exclusions and limitations).
 
Payment Info
 
Automatic Bank Withdrawal 

Use the following bank information for: 
All Options selected
 Option #1  ONLY
Option #2  ONLY
 
Bank Name:   Bank City State   Zip 
Get the following Information from the bottom of your check:
Routing Number               Account Number
':   123456789      ':        123   45678  9        ||'    1234  (Check number)
': ': ||'    Don't need check number
 
For your convenience, Aflac (#1) & DefinedMed (#2) will accept a credit card as payment.
If you would like to pay by that method, enter the information below:
Note: if you leave the sections below blank, we will process everything through the bank account above.
You will need to send in a VOID check with your signed paperwork the start the plans
 

Credit Card Option  Note: you can use Visa & MC on either option, but Amex only on Option #1 & Discover on Option #2

Option #1  ($102.09/month - Wife only):

Credit Card Type (Choose ONE)-    Visa        MC       American Express   
Credit Card Number    
Expiration Date (mm yy):  

Option #2:  (Apx $95/month.... see chart above)

Click here to use SAME Credit Card as Aflac (See above)

Or use the following card instead:

Credit Card Type (Choose ONE)-    Visa        MC       Discover  
Credit Card Number    
Expiration Date (mm yy):  

Enter Questions or Comments Below,
Enter the Code, then Submit Button to get an application...

  To Validate your submission,                        
Type this number:                          
in this box here >>>   <<< 
Note: if you don't type in this exact number, your submission
 will not be recorded! 

                                   Then click SUBMIT below...



Remember that your ZIP CODE will be your password to open the
Adobe Acrobat PDF Application you will receive by email
 

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