UniCare recognizes that what works for one doesn’t necessarily work for another. That’s why our full portfolio of health, pharmacy, dental, life and disability benefits products can be tailored to meet your specific needs.  Our focus is on putting our clients and their associates back in control of their health care and financial future. Through exceptional sales and account management staff who listen to our clients and their associates, we can create benefits that evolve over time to meet changing needs and add the most value.

1. Please Select Plan: Assurant BCBS GoldenRule HAP UniCare

PERSON(S) TO BE INSURED

1. Primary First & Last Name(required)
2. Gender: - Male Female (required)
3. Date of Birth:(required)
4. Height Ft: - 4 5 6 (required)
5. Height In: - 0 1 2 3 4 5 6 7 8 9 10 11 (required)
6. Weight:(required)
7. Social Security Number:

SPOUSE INFORMATION

1. Spouse First & Last Name
2. Spouse Gender: - Male Female
3. Spouse Date of Birth:
4. Spouse Height Ft: - 4 5 6
5. Spouse Height In: - 0 1 2 3 4 5 6 7 8 9 10 11
6. Spouse Weight
7. Spouse Social Security Number:

DEPENDENTS

2. Yes No
3. Dependent 1 Name:
4. Dependent 1 DOB:
5. Dependent 2 Name:
6. Dependent 2 DOB:
7. List Additional Dependents:

PERSONAL INFORMATION

1. Resident Address:(required)
2. City:(required)
3. State:(required)
4. Zip:(required)
5. Phone Number:(required)
6. Email Address:(valid email required)

 

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