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High Deductible Health Plan Application

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  • Service Overview
  • ReSure LLC provides a comprehensive solution for HSA Compatible Health Plan implementation and we look forward to working with you. Our ability to obtain a favorable medical insurance quote on your behalf depends on several factors, which vary by State and carrier. A key determinant is the size of your business, if any. Therefore, we can not guarantee that we will be able to provide you with an insurance quote. Based on your entries in this form submission, we will identify the best options for you. There is no fee associated with this form submission. To get started with your HSA-compatible health plan, please complete this form.
  • Your Personal Information
  • Physical Address
  • Group Health Insurance or Individual Health Insurance
  • Group Health Plans are, generally, more attractive than Individual Health Plans. Qualifying for Group Coverage requires that the Health Plan be obtained by a business, as well several additional factors that vary by State and insurance carrier. Based on your entries below, we will identify the best options that we can provide. Our ability to assist with Individual Coverage is limited by many States.
  • If applicable, please enter the renewal date of your current medical insurance plan.
    MM slash DD slash YYYY
  • Business Information
  • A Group Health Plan must be sponsored by a business. State law and insurer underwriting guidelines differ with regard to what constitutes a "Group" for medical insurance purposes.
  • Please indicate in which state(s) your business is based.
  • Please enter the full legal name of the business.
  • Please enter the primary address of the business.
  • Please enter the legal & tax structure of the business.
  • Please enter the number of business owners, partners or shareholders.
    Please enter a number greater than or equal to 0.
  • Business Employees
  • Does the business have any employees receiving W-2 wages? Include any business owners that are receiving W-2 wages from the business.
  • Please enter the total number of individuals receiving W-2 wages from the business.
  • Nature of Our Services to You
  • Your typed name above constitutes a signature.
  • MM slash DD slash YYYY
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