Applications

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          Application Instructions          
Contact Information :
Walter Palmer - (612) 825-4990
Cell: (612) 559-0961
FAX: (612) 345-5956
wpalmer@healthinsurancemn.com
state of minnesota
For Minnesota residents only
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Thank-you for visiting the healthinsurancemn.com website and I hope that you found the information you needed. Feel free to contact me during normal business hours. I will be happy to assist you if you have any questions or if you want a quote. If you would like Applications mailed to you, I can send them to you.

  Individual and Family Applications and Forms
 Individual/Family Plan Health Insurance App  VIEW 
( F10537R02_0917.pdf )  829 Kb
  Group Applications
 Enrollment Waiver and Change Form  VIEW 
( F10936_EmploymentWaiverForm.pdf )  596 Kb
 Small Group Business App  VIEW 
( F10538R02_2018 Small Group Business.pdf )  600 Mb
  Extra Coverage
 Individual and Family Dental and Vision App  VIEW 
( F10563R02_Dental-Vision.pdf )  562 Kb
  Other Forms
 Pay-O-Matic Authorization Form  VIEW 
( F1915r28_111978.pdf )  117 Kb
 HSA Forms: www.selectaccount.com
  Assurant Insurance
 Group Insurance Preliminary Application  VIEW 
( AssurantMasterApplication.pdf )  441 Kb
 Continued Employee Life Insurance  VIEW 
( k2689amn.pdf )  24 Kb
 Extended Employee Application  VIEW 
( k2831amn.pdf )  88 Kb
 Request to Elect Dental COBRA  VIEW 
( k3661a.pdf )  54 Kb
 Faxable Change Document  VIEW 
( k4034a.pdf )  69 Kb
 Specifics of the Minnesota Life Continuation  VIEW 
( k4240amn.pdf )  12 Kb