Step 1 of 2 0% Company InformationCompany Name*Name of company, DBA or sole proprietorship. Company Contact Name First Last Company Email HiddenSetup Fee AppliedHiddenSetup Fee WaivedHiddenBenefit Options Employee InformationName* First MI Last Additional Name Details Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. Suffix Date of Birth Month Day Year Select Age Group*Select the age group that you are in.Age 18-29Age 30-49Age 50-64Social Security Number or Tax ID* Gender* Male Female Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email PhoneCoverage TypeEmployee OnlyEmployee & SpouseEmployee & Child(ren)FamilySpouse Name First Middle Last Spouse Tax ID*Enter Tax ID or SSN for Spouse. Spouse DOB Month Day Year Spouse Gender Male Female Dependents*Important: Fields do not validate. Please enter date of birth using mm/dd/yyyy format. Please enter tax ID using xxx-xx-xxxx format. Use "+" button on right side to add additional dependents.First NameLast NameDate of BirthTax IDM/F Enrollment Plan Selection Select the plans that you wish to offer or enroll in. Additional setup may be required for some plan types.Select Base Health Plan - Employee Rate*You may select one preventive health plan or membership plan option. See plan options. Waive - $0 Preventive HSA - $75 monthly Copay Advanced - $175 monthly Select Base Health Plan - Employee & Spouse*You may select one preventive health plan or membership plan option. See plan options. Waive - $0 Preventive HSA - $120 monthly Copay Advanced - $250 monthly Select Base Health Plan - Employee & Child(ren)*You may select one preventive health plan or membership plan option. See plan options. Waive - $0 Preventive HSA - $120 monthly Copay Advanced - $250 monthly Select Base Health Plan - Family Rate*You may select one preventive health plan or membership plan option. See plan options. Waive - $0 Preventive HSA - $150 monthly Copay Advanced - $350 monthly Health Savings Account (HSA) Contribution I would like to contribute funds to an Health Savings Account (HSA) managed by Optum Bank. Health Savings Account (HSA) Contribution Amount*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. Please enter a number from 1 to 583.Select HealthShare - Employee Rate*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 Waive - $0 HealthShare @ $1,000 IUA - $150 monthly HealthShare @ $2,500 IUA - $100 monthly HealthShare @ $5,000 IUA - $75 monthly Select HealthShare - Employee Rate*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 Waive - $0 HealthShare @ $1,000 IUA - $175 monthly HealthShare @ $2,500 IUA - $145 monthly HealthShare @ $5,000 IUA - $125 monthly Select HealthShare - Employee Rate*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 Waive - $0 HealthShare @ $1,000 IUA - $225 monthly HealthShare @ $2,500 IUA - $200 monthly HealthShare @ $5,000 IUA - $150 monthly Select HealthShare - Employee + Spouse*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 Waive - $0 HealthShare @ $1,000 IUA - $300 monthly HealthShare @ $2,500 IUA - $200 monthly HealthShare @ $5,000 IUA - $150 monthly Select HealthShare - Employee + Spouse*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 Waive - $0 HealthShare @ $1,000 IUA - $350 monthly HealthShare @ $2,500 IUA - $250 monthly HealthShare @ $5,000 IUA - $225 monthly Select HealthShare - Employee + Spouse*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 Waive - $0 HealthShare @ $1,000 IUA - $450 monthly HealthShare @ $2,500 IUA - $375 monthly HealthShare @ $5,000 IUA - $300 monthly Select HealthShare - Employee + Child(ren)*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 Waive - $0 HealthShare @ $1,000 IUA - $300 monthly HealthShare @ $2,500 IUA - $200 monthly HealthShare @ $5,000 IUA - $150 monthly Select HealthShare - Employee + Child(ren)*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 Waive - $0 HealthShare @ $1,000 IUA - $350 monthly HealthShare @ $2,500 IUA - $250 monthly HealthShare @ $5,000 IUA - $225 monthly Select HealthShare - Employee + Child(ren)*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 Waive - $0 HealthShare @ $1,000 IUA - $450 monthly HealthShare @ $2,500 IUA - $375 monthly HealthShare @ $5,000 IUA - $300 monthly Select HealthShare - Employee + Family*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 Waive - $0 HealthShare @ $1,000 IUA - $450 monthly HealthShare @ $2,500 IUA - $350 monthly HealthShare @ $5,000 IUA - $250 monthly Select HealthShare - Employee + Family*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 Waive - $0 HealthShare @ $1,000 IUA - $500 monthly HealthShare @ $2,500 IUA - $400 monthly HealthShare @ $5,000 IUA - $350 monthly Select HealthShare - Employee + Family*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 Waive - $0 HealthShare @ $1,000 IUA - $700 monthly HealthShare @ $2,500 IUA - $575 monthly HealthShare @ $5,000 IUA - $450 monthly Do you use tobacco products?Additional $50 monthly fee is added for tobacco users. You should select yes if you have used tobacco products in the last 12 months. Yes, I use tobacco products. Medical Conditions Existing Prior to MembershipNeeds that result from a condition that existed prior to membership are only shareable if the condition is fully cured and 24 months have passed without any symptoms, treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.Member NameConditionLast Treatment Date HealthShare Standards Of Health*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. I agree to live by the HealthShare Standards of Health Zion Health's medical cost sharing membership is included as part of your Access Care membership at a $1,000 Initial Unsharable Amount (IUA).Do you use tobacco products?Additional $50 monthly fee is added for tobacco users. You should select yes if you have used tobacco products in the last 12 months. Yes, I use tobacco products. Medical Conditions Existing Prior to MembershipNeeds that result from a condition that existed prior to membership are only shareable if the condition is fully cured and 24 months have passed without any symptoms, treatment, or medication, even if the cause of the symptoms is unknown or misdiagnosed.Member NameConditionLast Treatment Date HealthShare Standards Of Health*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. I agree to live by the HealthShare Standards of Health Select Dental Plan - Employee Rate*Select your accident plan election. See dental plan to learn more. Waive - $0 Copay Plan - $25 monthly Standard Plan - $40 monthly Select Dental Plan - Employee & Spouse*Select your accident plan election. See dental plan to learn more. Waive - $0 Copay Plan - $50 monthly Standard Plan - $75 monthly Select Dental Plan - Employee & Child(ren)*Select your accident plan election. See dental plan to learn more. Waive - $0 Copay Plan - $50 monthly Standard Plan - $80 monthly Select Dental Plan - Family Rate*Select your accident plan election. See dental plan to learn more. Waive - $0 Copay Plan - $75 monthly Standard Plan - $120 monthly Select Vision Plan - Employee Rate*Select your vision plan election. See vision plan to learn more. Waive - $0 Copay Vision - $10 monthly Select Vision Plan - Employee & Spouse*Select your vision plan election. See vision plan to learn more. Waive - $0 Copay Vision - $15 monthly Select Vision Plan - Employee & Child(ren)*Select your vision plan election. See vision plan to learn more. Waive - $0 Copay Vision - $15 monthly Select Vision Plan - Family Rate*Select your vision plan election. See vision plan to learn more. Waive - $0 Copay Vision - $25 monthly Request Effective MonthEffective dates are the first of the selected month. We try to accommodate requested effective dates the best we can though there are sometimes limitations with the carrier providing coverage. We cannot back date coverage.JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Δ