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Unity HealthShare Gold Plan Application
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
Arthritis
Asthma
Heart Disease
Congestive Heart Failure
Heart Bypass Surgery
Depression
Diabetes Type I
Diabetes Type II
Chronic Heartburn/GERD
High Cholesterol
High Blood Pressure
Irritable Bowel Disease
Lower Back or Neck Pain
Heart Attack
HIV/AIDS
None of the above
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?
0-1 years
1-2 years
2-3 years
3-4 years
5+ years
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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 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
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