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PLANILLA DE INSCIPTION INDIVIDUAL

Agent/Agency Name:
Fl. Lic. No:
PMP Agent No:
Agent Phone No:
Plan:

PLEASE FILL THIS OUT

Last Name (Applicant/Apellido)
First Name / Nombre
MI / Inicial
Marital Status
Address
City
State
Home Phone.
Work Home Phone.

PLEASE LIST ALL PERSONS TO BE ENROLL

POR FAVOR NOMBRE TODAS LAS PERSONAS INSCRITAS

Please list of each person to be covered and complete the information requested, which Includes the Application (subscriber), spouse and eligible unmarried children ages 0-21 years age. Unmarried children, from age 19 up to age 21 must be be full time students. Proof of full time student must be provided, please attach proof of attendance. If the last name of any dependent is different from the Application (subscriber), please provide the appropriate documentation.

Last Name / First / Initial
APELLIDO /Nombre/ Inicial

Sex

Soc. Sec. No.

Date of
Birth

Riders

Primary Care Physician

Relationship

M/F

Dental

Eye

Name

Loc#

Application

Spouse

Dependent

FIRST MONTH'S PREMIUM AMOUNT DUE WITH APPLICATION-SUBMIT RATE SHEET WITH APPLICATION

Statement of Understanding
The undersigned Applicant declares that he or she has voluntarily applied for membership in Preferred Medical Plan, Inc (the " Health Plan"). The Applicant (Subscriber) affirms that he or she understands the rules and regulations of the Health Plan. There is no coverage or benefits for Pre-Existing Conditions for two years after the effective date of enrollment. Each person listed is subject to an underwriting examination and is aware that no benefits will be provided until the health Plan has completed and approved and the underwriting process and has notified the applicant in writing.
Applicant Subscriber agrees that failure to comply with the underwriting examination and complete the process within 30 days after the date of this application is cause for this application to be rejected by the health plan. If the Health Plan accepts the Applicant Subscriber and Dependents for enrollment, and the fee for each person listed above refuses enrollment, and the Applicant Subscriber and/or Dependants refuses enrollment in Health Plan, there is $75 processing fee for each person listed above that refuses enrollment. The acceptance of this applicant does not constitute a contract and it can not be used for bases of a claim.
Any person that knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an applicant containing any false, incomplete, or misleading information is guilty of a felony of the third degree. The contract between the Applicant and the Health Plan consist of this application and the Health Plan's Individual Medical and Hospital Service contract. A copy of the above mentioned Contract is available to the applicant.

When you fill out the box below you are bound as if it were your signature.


APPLICANT'S SIGNATURE / FIRMA DEL SOLICITANTE	DATE FECHA

Declaracion de Conocimiento
El que suscribe declara que ha solicitado volutariamente ingreso al Preferred Medical Plan, Inc.( el "Plan de Salud"). El Solicitante (Susciptor) afirma que entiende las reglas y regulaciones del Plan de salud. El Plan ne provee cobertura o beneficios para Condiciones Preexistentes durante los dos primeros anos de afiliacion, a partir de la fecha de efectividad de la fecha de la poliza. Cada una de las personas enumeradas debe someterse a un examen fisico completo y facilitar su historia clinico. El Solicitante no tendra derecho a reciber ningun beneficio hasta que el Plan de Salud haya dado por termidado y aprobado el processo de inscription, y haya notificado por escrito al solicitante. El Solicitante entiende que el no someterse al examen medico y terminar el proceso de inscipcion en un termino de 30 dias despues de la fecha de la solicitud sera causa suficiente para que la misma sea rechazada por el Plan de Salud. Habre un cargo de $75 para aquellos Solicitante o miembros del grupo familiar que rechacen la inscripcion al Plan de Salud no estableca un contracto y no puede usarse como base para una reclamasion. Cualquier persona que a sabiandas y con intencion de perjudicar, estafar o enganar presente una reclamacion o solicitud que contenga informacion falsa, incompleta o enqanosa sera culpable de un delito de tercer grado.
El contrato entre al Solicitante y el Plan de Salud consta de aste solicitud y el Contrato Individual de Servicios Medicos y hospitalarios. Este Contrato esta a la disposicion del Solicitante.


APPLICANT'S SIGNATURE / FIRMA DEL SOLICITANTE	DATE FECHA