Healthcare Indemnity Enrollment Forms
Please use the form specific to state of enrollment or generic if your state is not listed.
The following states are not yet approved for enrollment:
CA, CT, HI, ME, MD, MA, MN, NH, NJ, NY, OR, PA, PR, WA, WY
The forms are provided in the Adobe Acrobat (PDF) format. In order to open the files you need Adobe Reader installed on your computer. Download the latest version of Adobe Reader®.