Individual and Family Plan Applications

Application for Max Savings, Choice and Choice Plus Plans

Application for Basic and Preferred ACA Plans 


Please note: TruAssure cannot accept applications for individual insurance plans via fax or email. All applications must be mailed to TruAssure at the following address: TruAssure, Consumer Direct – Individual, PO Box 804307, Chicago, IL 60680-4104.


Notice to Applicant Regarding Replacement of Accident and Sickness Insurance for Max Savings, Choice, Choice Plus, Basic and Preferred Plans

NOTE: PLEASE SIGN ONE AND RETURN, AND SAVE THIS COPY FOR YOUR FILES.


Español


Solicitud para los planes Max Savings, Choice y Choice Plus

Solicitud de los planes ACA Basic y Preferred 2022


Por favor, note: TruAssure no puede aceptar solicitudes de planes de seguro individual por fax o correo electrónico. Todas las solicitudes deben ser enviadas a TruAssure a la siguiente dirección: TruAssure, Consumer Direct – Individual, PO Box 804307, Chicago, IL 60680-4104.

TruAssure Group Plan Forms

Group Application with Supplemental Form
Group Member Enrollment Form
Group Member Enrollment Form (Español)

Other Forms

Claim Form

Claims Appeal Procedures

TruAssure Payment Authorization

HIPAA Notice of Privacy Practice and Rights


Authorization for Release of Information

To complete with a digital signature and send electronically, please download this form with Adobe or another PDF reader.


Authorization for Release of Information (Español)

Para completar con una firma digital y enviar electrónicamente, por favor descargue esta forma por el Adobe u otro lector PDF.


Privacy Notice (Gramm-Leach-Bliley)

Non-Discrimination Notice

Non-Discrimination Notice (Español)