Health Care Sharing Ministry Plan Application When Do You Want Your Plan To Start?* Plans can start any day you'd like in the future (example: January 12, or February 15, or March 22). Your plan can start tomorrow, too.Legal Name* First Last Male or Female* Male Female Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Month Day Year Social Security #* Phone # for Text Message* Do You Want To Add A Spouse?* Yes No Do You Want To Add Any Children?* Yes No Spouse InformationName First Last Male or Female* Male Female Date of Birth* Month Day Year Social Security Number* Children InformationHow Many Children?* 1 2 3 4 Child's Name First Last Male or Female* Male Female Date of Birth* Month Day Year Social Security Number* 2nd Child's Name First Last Male or Female* Male Female Date of Birth* Month Day Year Social Security Number* 3rd Child's Name First Last Male or Female* Male Female Date of Birth* Month Day Year Social Security Number* 4th Child's Name First Last Male or Female* Male Female Date of Birth* Month Day Year Social Security Number* InformationThe CLASSIC plan provides $500,000 per medical incident (the COMPLETE plan provides $1,000,000). Do you want to increase that to $1,000,000 per incident for an additional monthly cost of $130 for one person, $230 for two people, and $330 for three or more people.* Yes Increase It No Do Not Increase It I am applying for the COMPLETE plan Statement of Beliefs - We believe in the sanctity and dignity of every human life, and that God created every life for a special meaning and purpose. Psalm 139:13-14 - We believe that every individual has the constitutional and religious right to worship God in freedom. 2 Corinthians 3:17 - We believe and agree in the biblical and ethical principle of sharing with those who are less fortunate and who experience medical needs. Galatians 6:2 - We believe and agree that it is our responsibility to God and our fellow members to engage in healthy living, and to avoid habits and behaviors which are harmful to the body. 1 Corinthians 6:19-20 - We believe in the power of prayer, and that prayer should be a fundamental practice of daily life. 1 John 5:14. Do you agree?* Yes I Agree No I Do Not Agree Health conditions - check all that apply:* Arthritis Asthma Heart Disease Congestive Heart Failure Heart Bypass Surgery Behavioral/Mental Health Diabetes Type I Diabetes Type II High Cholesterol High Blood Pressure Crohn's Disease Lower Back Pain Herniated Disc HIV/AIDS Eating Disorder Anyone hospitalized in last 6 months COPD None of the above These plans give you a life insurance benefit. Please indicate who should be designated as your primary End Of Life Sharing Recipient (beneficiary):* Please indicate who should designated as your secondary End Of Life Sharing Recipient: Are you currently participating in a HealthShare Program?* Yes No In the past 24 months have you received medical services, treatment or advice?*Starting Today, going back 24 Months Yes No If Yes, please list date, physician who treated and diagnosis: If No, enter Not Applicable* Do you use tobacco in any form?* Yes Tobacco User No Smokers Do you have or ever had Cancer?* Yes I have or had cancer No I have never had cancer If you had Cancer, how long ago? 0-1 years 1-2 years 2-3 years 3-4 years 5+ years Do you play in any extreme or professional sports?* Yes No If Yes, list the extreme or professional sports you play in:*Do you drink alcohol?* Yes I Drink No I Do Not Drink If you drink Alcohol, what is your weekly intake?* 1-3 weekly 4-7 weekly 8+ weekly Are you pregnant?* Yes I am pregnant No I am not pregnant If applicable, does anyone else in your family applying have any of the above conditions, diseases, and/or ever have or had cancer? Check all that apply. Spouse Child 1 Child 2 Child 3 Child 4 None If applicable, please fill out any dependent medical information.*Monthly Billing InformationDo you want to pay your monthly fee by credit/debit card or checking account?* Credit/Debit Card Checking Account Card Type* VISA MasterCard American Express Discover Credit/Debit Card #* Expiration Date* MM/YYCVC Number* three digits on back, or four digits on front if American ExpressIs the Billing Address the Same as Above* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bank Name* Account Holder Name* First Last Bank Routing #* Bank Account #* Note: Your first monthly payment is processed immediately upon application submission (unless we have told you differently). We cannot sign your application for you. Soon after we submit your application, you will receive an email or a text message from OneShare that you must respond to. Your response will act as your signature. Do you want to receive a text message or an email so that you can sign? A text message is much easier.* Send Text Message Send Email CAPTCHA
