GCSAA Insurance Inquiry Form

This form provides AHP the necessary information to be able to advise you. It is not shared with any other entity and/or used for any other purpose. Please CLICK HERE if you are inquiring for a company. TERMS OF SERVICE: Assistance is only available to members. GCSAA is not a group. Membership does not guarantee eligibility for insurance policies. We advise what is best for each member based on his or her situation with the options available within the healthcare system. Product availability, rates, and eligibility vary by state, individual circumstances, and insurance companies' guidelines. There are no options available in AK, CA, CT, HI, MA, ME, NH, NJ, NY, RI, VT, and WA due to state restrictions.
*Required
I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF SERVICE NOTED ABOVE* (Type "Yes" in order to proceed)

MEMBERSHIP NUMBER*
COURSE / FACILITY NAME*
ARE YOU ELIGIBLE FOR AND/OR RECEIVING MEDICAID OR A MARKETPLACE SUBSIDY?*

MEMBER DETAILS
FIRST & LAST NAME*
RESIDENTIAL ADDRESS*
CITY*
STATE*
ZIP*
COUNTY*
EMAIL*
PHONE*
GENDER*
DATE OF BIRTH*
TOBACCO USER?*
HEIGHT & WEIGHT*
ANY HEALTH CONDITIONS* IN THE LAST 5 YEARS?*
If yes, please provide the name(s) of the condition(s). *Received medical or surgical consultation, advice, treatment, and/or medication for.

SPOUSE DETAILS (IF TO BE INCLUDED)
FIRST & LAST NAME
GENDER
DATE OF BIRTH
TOBACCO USER?
HEIGHT & WEIGHT
ANY HEALTH CONDITIONS* IN THE LAST 5 YEARS?
If yes, please provide the name(s) of the condition(s). *Received medical or surgical consultation, advice, treatment, and/or medication for.

CHILDREN DETAILS (IF TO BE INCLUDED)
Please provide each child's full name, gender, DOB, height, weight, and health conditions (if any).
CHILD 1
CHILD 2
CHILD 3
CHILD 4
CHILD 5

ANYONE PREGNANT?*
If yes, please include the due date.

INSURANCE PRODUCTS OF INTEREST*
(e.g. health, dental, vision, etc.)

REASON FOR INQUIRING*
(e.g. job change, premium too high, poor network, not insured, etc.)

IF NOT INSURED, HOW LONG HAVE YOU BEEN WITHOUT? (TYPE N/A IF YOU ARE INSURED)*

IF YOU ARE INSURED, PLEASE SPECIFY IF YOU HAVE AN INDIVIDUAL POLICY OR A GROUP POLICY THROUGH EMPLOYMENT (TYPE N/A IF YOU ARE NOT INSURED)*

DESIRED EFFECTIVE DATE*

PLEASE PRESS SUBMIT AND WE WILL CONTACT YOU WITHIN TWO BUSINESS DAYS.