Name of company, DBA or sole proprietorship.

Select the age group that you are in.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

You may select one preventive health plan or membership plan option. See plan options.

The amount entered will be added to your Preventive HSA plan and deposited into your Health Savings Account (HSA) account. The account will be with Optum Bank. You will receive a debit card that will allow access to these funds for qualified medical expenses.

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 18-29

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 30-49

You may select one catastrophic plan. You have the choice of a $1,000, $2,500 or $5,000 Initial Unshareable Amount (IUA). See plan options. Ages 50-64

By joining a HealthShare, you agree to live by the stands of good health. These standards include avoiding illegal drugs and excessive alcohol use. It is encouraged to try and maintain a healthy life style including exercise and proper nutrition.

Select your dental plan election. See dental plan to learn more.

Select your dental plan election. See dental plan to learn more.

Select your dental plan election. See dental plan to learn more.

Select your dental plan election. See accident plan to learn more.

Select your vision plan election. See vision plan to learn more.

Select your vision plan election. See vision plan to learn more.

Select your vision plan election. See vision plan to learn more.

Select your vision plan election. See vision plan to learn more.

By signing below, I affirm that the information above is correct and wish to enroll or waive as outlined above. I authorize the release of any medical information required to implement the plans selected. I also authorize the payroll deduction for any employee responsibility of the benefits selected.