Individual Coverage

INDIVIDUAL INFORMATION (Unless specified, all information is required to process) *NOT Required
Contact Name
Phone	*
Fax	*
E-mail
Street Address	*
City
State
Zip

Date of Birth (mm/dd/yy)
Gender
Albuquerque Metro Residence?
Smoker/Non-Smoker?

Dependent(s) Information
Are any dependents applying with you?	If yes, please complete the following section. If no, please skip this section.
Do you have a spouse that is applying with you?
His/Her Name
His/Her Date of Birth (mm/dd/yy)
Spouse's Gender
Albuquerque Metro Residence for spouse?
Is spouse Smoker/Non-Smoker?

Please list any eligible dependent children applying with you, their date(s) of birth, and whether they reside in the Albuquerque Metro Area. Example: Matt Rodriguez, 07/16/2003, Albuq. Metro

Plan Design
Requested Effective Date (mm/dd/yy) (this cannot be guaranteed)
Do you have a preference for a certain physician?	If yes, their name: *
Do you prefer a specific carrier?		(Please note: If your current physician contracts solely with Presbyterian, you may not have access to them should you elect coverage through Blue Cross Blue Shield of New Mexico and vice-versa)
Do you any interest in a Health Savings Account (HSA) type plan design?	Yes, I am only interested in HSA quotes Yes, but please include quotes for traditional individual medical insurance I don't know, please contact me to explain what an HSA is and how it works No, I am not interested in an HSA
Is there anything medically relevant about you or anyone applying that you feel we should be aware of?		*
Supplying us with this information does not in any way obligate you or your dependents to enroll, nor is there any cost associated with this part of the process. The information simply allows us to start the process of requesting a quote. Personal and more detailed information about those applying will be required later when completing the application, but that part of the process will not be performed online.