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 (employer/employee relationship or employee organization). Membership does not guarantee eligibility for insurance policies. We advise what is in the best interest of each member based on his or her situation and 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 ANY OTHER KIND OF GOVERNMENT FINANCIAL ASSISTANCE?*

MEMBER DETAILS
FIRST & LAST NAME*
RESIDENTIAL ADDRESS*
CITY*
STATE*
ZIP*
COUNTY (NOT COUNTRY)*
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.

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.

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 provide the due date.

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

REASON FOR INQUIRY*
(e.g. job change, divorce, premium too high, poor network, uninsured, etc.)

IF UNINSURED, HOW LONG? (TYPE N/A IF YOU ARE INSURED)*

IF *INSURED, DO YOU HAVE AN INDIVIDUAL POLICY OR IS IT THROUGH EMPLOYMENT? (TYPE N/A IF YOU ARE UNINSURED)

DESIRED EFFECTIVE DATE*

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