Will any anyone applying
to be insured need coverage beyond MN State maximum of 365 days?
Yes
No
Maybe
Would you like
to be contacted regarding a Cost Effective Permanent health
plan?
Yes
No
If yes, when?
Will any person applying
for coverage reside outside of Minnesota for the duration of
coverage?
Yes
No
Has anyone applying for coverage been diagnosed or treated within the past 5 years for a MAJOR DISORDER of the heart, lungs, kidneys, or liver, or been treated for a stroke, cancer, or diabetes, or is anyone currently pregnant or expecting to add a dependent through adoption?
Yes
No
If you answered yes to any of the above questions your application might be declined by the health insurance underwriter. If you would like to discuss your medical history or are interested in cost effective guaranteed issue coverage, contact Steven A Ehlen directly at 888-577-1142.
Yes
No
Click
continue for the rest of the application. Print and fill out application then send to BCBS address in upper left corner of application along with full contract premium based on age and desired duration of coverage .
