TIP SHEET

Illinois Standard Health Application for Individual & Family Health Insurance Coverage Packet For Individual Medical Underwriting Step 1: Complete the application and forms This packet includes the necessary forms you’ll need to submit your application with us.                           !    "     #           $ %&  (all applicants age 18 and over must sign)  "'  (     )*       

 + 5     with the applicant and not be submitted to us. Any dependent age 18 or over should have an opportunity to review this page of the packet.          * 5  6    !      )*779 #  5: these forms can be found on assuranthealthsales.com ; 9   !G]=N;

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      _      correspondence electronically.

Email Address ________________________________________________________________________________________ 9 + 9  _GX==

ILLINOIS INDIVIDUAL HEALTH INSURANCE ADDITIONAL NOTICES NOTIFICATION REGARDING MIB, Inc. (“MIB”) formerly known as the MEDICAL INFORMATION BUREAU      !%!     7(       :%:  )  !     : 7:  )%        :  NN !   &     :%    \ !  ! 7   !     :  !   !    :: B :%   %  ! 7 $    B   :  %            7 9      >YY Y]GNY]X=*((~>YYJOYNJYOG57B    D :     )    %       @7(

 D    MX 9 ): OXX: :   XG=>ON>[JO7 (   :   :          %      :%  !  ! ! 7    ! may be obtained on its website at www.mib.com. ABBREVIATED NOTICE OF INSURANCE INFORMATION PRACTICES (          : %    !    !            insurance. Some of that information will be received from you, and some will be generated from other sources. That information    ! B     !            !           %   & 7~     %    !\  %      7%      \       :     (     : $ % ' : MX= ^   : % ): ^  :MJGXJ7 FRAUD NOTICE It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose         79     : :    :   damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or   %     %    !   :  ! '    %' @  7 PRIVACY ^       N!      !           : \   ! %7^N!  !%