When Do You Want Your Plan To Start?*

Plans can start the first of next month, or on the first of the next two months (example: January 1, or February 1, or March 1)

Legal Name*

First Last

Male or Female*

Male
Female

Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

MM

DD

YYYY

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 Information

Name

First Last

Male of Female*

Male
Female

Date of Birth*

MM

DD

YYYY

Social Security Number*

Children Information

How Many Children?*

1
2
3
4

Child's Name

First Last

Male of Female*

Male
Female

Date of Birth*

MM

DD

YYYY

Social Security Number*

2nd Child's Name

First Last

Male of Female*

Male
Female

Date of Birth*

MM

DD

YYYY

Social Security Number*

3rd Child's Name

First Last

Male of Female*

Male
Female

Date of Birth*

MM

DD

YYYY

Social Security Number*

4th Child's Name

First Last

Male of Female*

Male
Female

Date of Birth*

MM

DD

YYYY

Social Security Number*

Information

This policy provides $500,000 per medical incident. Do you want to increase that to $1,000,000 per incident for an additional monthly cost of $130?*

Yes Increase It
No Do Not Increase It

At the core of what Aliera HealthCare does, and how they relate to and engage with one another as a community of people, is a set of common beliefs: 1. We believe that our personal rights and liberties originate from God and are bestowed on us by God. 2. We believe every individual has a fundamental religious right to worship God in his or her own way. 3. We believe it is our moral and ethical obligation to assist our fellow man when they are in need according to our available resources and opportunity. 4. We believe it is our spiritual duty to God and our ethical duty to others to maintain a healthy lifestyle and avoid foods, behaviors or habits that produce sickness or disease to ourselves or others. 5. We believe it is our fundamental right of conscience to direct our own healthcare, in consultation with physicians, family or other valued advisors.*

Yes I Agree
No I Do Not Agree

You acknowledge the first two months of contribution will be used as administration fees by Aliera HealthCare:*

Yes
No

Health conditions - check all that apply:

Do you use tobacco in any form?*

Yes Tobacco User
No Smokers

Smokers pay an additional $60 per month

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?

Do you play in any competitive sports?*

Yes I play competitive sports
No I do not play competitive sports

If Yes, list the competitive 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 Information

Do 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/YY

CVC Number*

three digits on back, or four digits on front if American Express

Is the Billing Address the Same as Above*

Yes
No

Address*

Street Address Address Line 2 City 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 to Aliera HealthCare. We cannot sign your application for you. Soon after we submit your application, you will receive an email or a text message from Aliera HealthCare that you must respond to. Your response will act as your signature. You will not be charged and your plan will not go into effect if you don’t respond.

Do you want to receive a text message or an email?*

Send Text Message
Send Email

Unity HealthShare Gold Plan Application

Spouse Information

Children Information

Information

Monthly Billing Information