Individual and Family Plan Applications

Application for Max Savings, Choice and Choice Plus 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.


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Solicitud para los planes Max Savings, Choice y Choice Plus

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.

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)