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
        See our Privacy Statement        
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 2017  VIEW 
( Ind_Fillable_Enrollment.pdf )  2,370 Kb
 Employee Enrollment Waiver  VIEW 
( 2016SGEmployEEEnrollmentWaiver.pdf )  215 Kb
  Group Applications
 Small Group Employee Enrollment Form  VIEW 
( f10145r04.pdf )  189 Kb
 Small Business Application  VIEW 
( 2017 Small Business Application.pdf )  2.24 Mb
  Assurant Insurance
 Group Insurance Preliminary Application  VIEW 
( Assurant Master Application.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
  Other Forms
 Pay-O-Matic Authorization Form  VIEW 
( F1915r28_111978.pdf )  117 Kb
  Dental Coverage
 Blue Cross Dental Individual and Family App  VIEW 
( mbe_f10563_4310.pdf )  257 Kb
 HSA Forms: www.selectaccount.com
Electronic Submittal Applications Available Electronic Applications