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.
 

Español


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.

TruAssure Group Plan Forms

Group Application with Supplemental Form
 

Group Member Enrollment Form (2-50 employees)

(Note: this is the application required by Wisconsin for employees of groups of 2-50 employees. This link will direct you to the Wisconsin Office of the Commissioner of Insurance (OCI) website.)


Group Member Enrollment Form (51 or more employees)

(Note: Please use TruAssure’s Group Member Enrollment Form for employees of groups with 51 or more eligible employees.)


Group Member Enrollment Form (Español) 

(Note: Please use TruAssure’s Group Member Enrollment Form for employees of groups with 51 or more eligible employees.)

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)