446 4th Street Columbus,IN 47202 Phone:(812)379-4780 | Fax:(812)379-4150

Individual Medical

Step 1

Applicant Information

First Name
Last Name
Phone Number
Email
State of Residence
Zip Code
County
Gender	MaleFemale
Date of Birth
Prescriptions Taking
Tobacco / Nicotine Use	YesNo

Step 2

Family Information

Spouse Gender	MaleFemaleNot Included
Spouse Date of Birth
Prescriptions Taking
Spouse Tobacco / Nicotine Use	YesNo
Number of Dependent Children to be Covered

Step 3

Plan Information

Plan Type
Deductible
Doctor Copay
Coinsurance
Rx Card
Maternity Care
Dental
Effective Date