Short Term — Perno Insurance Benefits

Short Term Health Insurance

IS SHORT TERM MEDICAL RIGHT FOR ME? IT CAN BE AN AFFORDABLE SOLUTION IF YOU’RE:

Waiting for open enrollment
Between jobs
Waiting for employer benefits
Temporary or seasonal workers

*Note: Short Term Medical Plans are not minimum essential coverage (not considered Creditable Coverage per A.C. A Rules and do not cover preventive services or routine care.

Name

First Name

Last Name

Date of Birth

YYYY

Email Address

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Medical Carrier

Tobacco Use

Gender

Spouse

First Name

Last Name

Date of Birthday

YYYY

Tobacco Use

Child #1

First Name

Last Name

Date of Birth

YYYY

Gender

Tobacco Use

Child #2

First Name

Last Name

Date of Birth

YYYY

Gender

Tobacco Use

Child #3

First Name

Last Name

Date of Birth

YYYY

Gender

Tobacco Use

Child #4

First Name

Last Name

Date of Birth

YYYY

Gender

Tobacco Use

What is the best time to call you?

Hour

Minute

Second