Golden Rule Online Application

Golden Rule Insurance Company has been a leader in the individual health market for more than 60 years and offers a wide variety of affordable health insurance plans, including Health Savings Accounts (HSAs), a plan they pioneered. Serving individuals and families is our primary focus. Because we are dedicated to this market, we have developed a unique understanding of the health insurance needs of individuals and families. This knowledge is reflected throughout your experience with Golden Rule — in our high quality products, our handling of claims, and our customer service. Golden Rule is rated “A” (Excellent) by A.M. Best, independent analysts of the insurance industry. This rating indicates financial strength and stability.

Please Select Plan:

PERSON(S) TO BE INSURED

Primary First & Last Name(required)
Gender:(required)
Date of Birth:(required)
Height Ft:(required)
Height In:(required)
Weight:(required)
Social Security Number:

SPOUSE INFORMATION

Spouse First & Last Name
Spouse Gender:
Spouse Date of Birth:
Spouse Height Ft:
Spouse Height In:
Spouse Weight
Spouse Social Security Number:

DEPENDENTS

Yes No
Dependent 1 Name:
Dependent 1 DOB:
Dependent 2 Name:
Dependent 2 DOB:
List Additional Dependents:

PERSONAL INFORMATION

Resident Address:(required)
City:(required)
State:(required)
Zip:(required)
Phone Number:(required)
Email Address:(valid email required)

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Golden Rule Online Application

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