Health Insurance

Health insurance is so confusing nowadays. Where does one even begin trying to figure out what coverage to have? The answer to that question is easy. Start with us, Demulling & Slama Insurance. We guide you through the sea of options and variables, backed with the experience to help you make the best decisions for your needs. We work with select insurance carriers to offer you medical, dental, and vision insurance coverage options for individuals, families, and employers with group benefit plans. We also offer Medicare Supplement and Medicare Advantage Plans.

Things change quickly and continuously when it comes to health insurance coverage needs. Variables such as growing older, marrying, starting a family, and accidental injuries can all affect your insurance needs. Along with these, medicines, equipment, pharmaceuticals, and treatments are also always evolving. So it's difficult to know how to navigate these factors to find affordable and practical solutions with health coverage. We are experts in finding and securing appropriate health coverage, so let us do the legwork for you. Please fill out the Health Insurance Application below or contact us to discuss your health insurance needs today!

Health 2021

Applicant Information

Today's Date

First Name

Last Name

Email Address

Phone Number

Do you need health insurance for you personally/family or for your business? *

Personally / Family

Business

Business Information

Name of Business:

Business Address:

Street Address 1

Street Address 2 / Apt / Unit / Ste

City

State/Province

Zip/Postal

Country

Nature of Business:

Type of Company:

Current Health Insurance Carrier Name:

Current Plan Design:

HMO

PPO

HSA

HRA

Deductible Amount: $

Co-Insurance:

Out of Pocket Cost: $

(excluding deductible)

Office Visit Co-Pay Amount: $

Drug Card Co-Pay Amount : $

Employee Information

How many employees are there:

Employee 01

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 02

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 03

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 04

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 05

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 06

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 07

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 08

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 09

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 10

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 11

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 12

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 13

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 14

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 15

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 16

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 17

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 18

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 19

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

Employee 20

Employee Name / Initials:

Gender:

Male

Female

Date of Birth / Age:

Tobacco Use:

Yes

Health Coverage Elected:

Number of Children:

State and Zip Code:

20+ Employees

Please upload a list of employees including the information listed next.

Employee Name / Initials, Gender, Date of Birth / Age, Tobacco Use (Yes / No), Health Coverage Elected (see key below), State & Zip Code

Health Coverage Elected Key:

E = Single Coverage
ES = Employee & Spouse
EC = Employee & Children - please add number of children
F = Family Full Coverage - please add number of children
W = Waiving (declining) Coverage / Life Only
COBRA / Continuation

Please upload file here.

Maximum upload size: 516MB

If you are human, leave this field blank.

>>> Fill Out Form Here <<<

I cannot thank the wonderful people at Demulling & Slama enough for taking the confusion and stress out of getting health coverage.

Health Insurance Application

Applicant Information

Business Information

Employee Information

Employee 01

Employee 02

Employee 03

Employee 04

Employee 05

Employee 06

Employee 07

Employee 08

Employee 09

Employee 10

Employee 11

Employee 12

Employee 13

Employee 14

Employee 15

Employee 16

Employee 17

Employee 18

Employee 19

Employee 20

20+ Employees

Employee Name / Initials, Gender, Date of Birth / Age, Tobacco Use (Yes / No), Health Coverage Elected (see key below), State & Zip Code