Home | About Us | Enroll Now! | Request Assistance  
Your Agent: SCRUGGS INSRUANCE AGCY INC

tommy@scruggsinsurance.com
 

Plan Highlights

What are the plan benefits?

Who is eligible?

How do I apply?

When is coverage effective and for how long?

What are the plan limitations and exclusions?

SSL  

Please fill out the form below, and then click the Continue button to proceed to the next step of the enrollment process.

Effective Date
Requested Effective Date:  help

Plan Options
Deductible:  help
Coinsurance: 
help
Supplemental Accident Benefit:  help
Coverage Period Maximum Months: 
Payment Frequency:  help
Number of Months:     OR   Optional Termination Date:   help

Agent Information
Were you referred to this site by another insurance agent not shown above as "Your Agent"? 

Applicant Information
Have you been insured under an Allied short term plan in the last six months?: 
First Name: 
Middle Initial: 
Last Name: 
Social Security #:   Ex: 123-45-6789
Address: 
City: 
State: 
Zip Code: 
Daytime Telephone Number:   Ex: 123-456-7890x1234
Email Address:   Ex: name@name.com
Date of Birth:   Ex: 01/01/2000
Gender: 

Credit/Debit Card Billing Information
First Name: 
Last Name: 
Address: 
City: 
State: 
Zip Code: 

Spouse/Children Information
Applying For: 
Number of Dependents: 
Spouse's Social Security #: 


Medical Information
Question A
Are you or any Dependent to be insured currently pregnant or receiving infertility treatments, or if insuring dependents, are you an expectant father or in the process of adoption or in the process of surrogate pregnancy?
Question B
Within the last five (5) years, have you or any Dependent to be insured been hospital confined for any reason (other than bodily injury) for four (4) consecutive days or longer?
Question C
Are you or any Dependent to be insured overweight AND been diagnosed with high blood pressure (whether or not treated or controlled)? Overweight is any male over 300 pounds or female over 250 pounds.
Question D
Are you or any Dependent to be insured overweight AND been diagnosed with elevated cholesterol (whether or not treated or controlled)? Overweight is any male over 300 pounds or female over 250 pounds.
Question E
Within the last five (5) years, have you or any Dependent to be insured, seen or been treated by any medical professional, or been recommended to see a medical professional, or received diagnostic testing, or received medication, or received abnormal test results for, or been diagnosed with, any of the following conditions?
  • Alcohol Abuse, Alcoholism, Chemical Dependency or Substance Abuse;
  • Cancer or Tumor (excluding basal cell);
  • Chronic Obstructive Pulmonary Disease, Cystic Fibrosis, Emphysema, Pulmonary Embolism or Tuberculosis;
  • Diabetes;
  • Organ or Tissue Transplant;
  • Blood disorder - including but not limited to hemophilia or leukemia;
  • Heart disorder – including but not limited to chest pain, heart failure, rhythm disturbances or heart attack;
  • Circulatory system disorder – including but not limited to stroke or deep vein thrombosis/phlebitis (does not include high blood pressure);
  • Immune disorders - including but not limited to Lupus, Human Immunodeficiency Virus (HIV), Acquired; Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC);
  • Kidney or Liver disorder - including but not limited to Hepatitis, Polycystic Kidney Disease or Renal Failure;
  • Nervous System disorder – including but not limited to Muscular Dystrophy; or· Mental/Nervous disorder requiring hospitalization
  • Question F
    Within the last twelve (12) months, have you or any Dependent to be insured been advised by any medical professional to have any medical treatment, diagnostic testing or surgery that has not been completed?
    Question G
    If all persons to be insured are United States citizens, please answer “No” to this question. If any person to be insured is not a United States citizen, has that person resided outside the United States at any time over the last 24 months?