Application Instructions

Section A: Applicant Information

Complete this section for everyone who needs coverage. Coverage is available for applicants ages 1-64 as of the
requested effective date. For Child-Only coverage, please indicate the child’s information in the Applicant Information
section. Child-Only coverage is for ages 1-17. Parent signature is required.

Section B: Product and Coverage Selection

Requested Effective Date – Select when you would like your coverage to begin. Mark 1st of the Month following application date or if other, mark Other date and select the month from the drop down menu.

Length of Coverage – Mark the box that corresponds to the length of time you will need coverage.

Deductible Amount – Mark the deductible amount you wish to have on your plan.

Optional Benefits Selection

• Reissue Rider – Mark the box that corresponds with the length of time you are requesting coverage. The initial Length of Coverage must be 6 months to consider this rider. Additional premium will apply.
• Maternity Benefit Rider – Please contact Cox HealthPlans for additional information at (417)269-4679.
• Autism Benefit Rider – Please contact Cox HealthPlans for additional information at (417)269-4679.

Section C: Application Questions

Complete all questions for all applicants. Only complete for those applying for coverage.

Section D: Referral Information

Indicate how you became familiar with Cox HealthPlans.

Section E: Agent Certification

If you are working with an agent please enter their name in this section.

Section F: Electronic Consent

Complete this section if you would like to have plan documents or notices regarding your policy delivered to you by electronic means.

Section G: Authorization

Review the conditions of application submission and underwriting process.

Section H: Payment

Enter the estimated total monthly premium for all applicants using the rate sheet.

Authorization Agreement for Short-Term Direct Debit

Complete the banking and authorization for monthly premium payments upon approval of the application.

Submit & Pay

All adults applying for coverage must sign and date the application, including the primary applicant, spouse and each dependent age 18 or older.

For Child-Only (ages 1-17) policies, a parent or legal guardian must sign and date the application as the Personal
Representative of the minor child(ren).