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 PhoneEmail* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Month Day Year 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 InformationName First Last Male of Female* Male Female Date of Birth* Month Day Year Social Security Number* Children InformationHow Many Children?* 1 2 3 4 Child's Name First Last Male of Female* Male Female Date of Birth* Month Day Year Social Security Number* 2nd Child's Name First Last Male of Female* Male Female Date of Birth* Month Day Year Social Security Number* 3rd Child's Name First Last Male of Female* Male Female Date of Birth* Month Day Year Social Security Number* 4th Child's Name First Last Male of Female* Male Female Date of Birth* Month Day Year Social Security Number* InformationHiddenThis 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 monthDo 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 InformationDo 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/YYCVC Number* three digits on back, or four digits on front if American ExpressIs the Billing Address the Same as Above* Yes No Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed 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
