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INDIVIDUAL UNIFORM APPLICATION
FOR INDIVIDUAL MAJOR MEDICAL
HEALTH INSURANCE FORM
Ref: Section Ins 3.33, Wis. Adm. Code,
and s. 601.41 (10), Wis. Stat.
State of Wisconsin
Office of the Commissioner of
Insurance
P.O. Box 7873
Madison, WI 53707-7873
(608) 266-3585
Web Address: oci.wi.gov
This form is designed for an individual’s initial application for coverage. Please contact the insurer
with questions regarding this form.
Instructions: Please complete the entire application for each person for whom coverage is being
sought. If a person is currently enrolled in Medicare, this application should not be completed for
that enrolled individual. If additional pages are needed to fully complete this application, please
attach, sign and date each page.
I. INFORMATION
Primary Applicant/Insured Information:
First, Middle and Last Name
Social Security No.*
Place of Birth Birth Date Gender Height ______
Weight ______
Residential Address
City
County State Zip Code
Mailing Address, if different from residential address
City
County State Zip Code
Home Phone
Alternative Phone Email (Optional)
*If you have a Social Security Number.
The Primary Applicant is:
[ ] Single [ ] Married [ ] Under the age of 18**
**If primary applicant is under the age of 18, please complete sections – II. C. and V.
Employment Information:
Primary job duties:
Self-Employed: [ ] Yes [ ] No
II. ADDITIONAL APPLICANTS
A. Please complete ONLY if your spouse and/or children under the age of 27 are applying for coverage.
If there is not enough space provided, please attach additional family information. Please sign and
date the additional sheet.
Spouse Name
(First; M.I.; Last)
Gender
Social Security
Number*/
Place of Birth
Birth Date
(Mo/Day/Yr)
Height
Weight
Primary Job Duties
(if applicable)
* If you have a Social Security number.