Your Short Term Health Insurance Solution


Referring Agent is: Lashona B Mcfadden

Select Your Plan Options
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Quote Info

Applicant Information

Please complete the following information to enroll. This information is considered strictly confidential and will only be used for enrollment and administration of your Short Term Health Insurance Plan.

After completing this form, press the Next button at the bottom of the form to advance to the second page where you will be asked to select a plan.

Your email address will only be used to send insurance policy information. Contact TCC (800-851-6268) if you do not receive an ID Card within 72 hours. If you check No Email - all documentation, ID Cards, etc. will be mailed to the applicant's address. Please note, this may delay the processing and receipt of documents and information.

Plan Selection

Please select the desired health plan, effective date and length of coverage.
(30, 60 or 90 days) Click here to view Plan Brochure.
Premiums are based on the gender and age of the applicant at the end of each coverage period. Premiums may vary depending on the effective date selected.

Policies with effective date 1/1/2018 - 12/31/2018, rates includes premium plus federal HII fee.

Health Questions

Answer all the following questions completely and accurately: (Required)
1. Do you currently have any health insurance that will not terminate prior to the requested effective date of this policy?

2. In the last five years, have you received treatment, medication or consultation for, or had an abnormal test result indicating you may have: multiple sclerosis; chronic obstructive pulmonary disease (COPD) or emphysema; HIV or AIDS; hepatitis C; a connective tissue disorder; any internal tissue, bone or blood cancer; malignant melanoma; a liver disorder; diabetes, except gestational; kidney disease or failure; a stroke; a heart attack, failure or disease; uncontrolled hypertension; alcohol or drug abuse or misuse; rheumatoid arthritis; bipolar disorder or schizophrenia; or an eating disorder?
3. Are you currently pregnant or suspect you may be pregnant?
4. In the last 12 months, have you consulted a doctor for, been advised to have, or considered undergoing a surgical procedure that has not yet been performed?
5. In the last six months, have you had symptoms for which you considered consulting a doctor, but did not?
6. In the last six months, have you consulted a doctor after which further testing was discussed or a referral to another doctor was suggested?

Final Review

Please verify the information below. If this is not correct, please select the Prev button and make the necessary changes to your application selections before continuing.

Note: You will be given the option to pay Monthly Premiums or pay the Total Premium in full at the end of this application.

*Policies starting 1/1/2018 - 12/31/2018, rates include Federal HII Fee.


Please carefully read the statement below in its entirety. When finished, acknowledge that you have read and agree with the statement by clicking the Checkbox below.
I Understand that:

The policy applied for provides single-only coverage (no family coverage is available); and
Pre-existing conditions are not covered by this policy; and
The coverage under this policy is not renewable; and
The policy will not be issued to a person under the age of 12 months or who will attain age 65 during the Policy Term.

It is fully understood and agreed that (1) the Company has the right to accept or reject coverage; (2) no insurance coverage shall be in force until the Company receives the application, approves coverage and assigns the date on which coverage shall become effective; and (3) any premium or Application fee submitted herewith may be retained by the Company pending approval of coverage. If any coverage is approved, the Company will retain the premiums and the Application fee. If no coverage is approved, the Company will return any premium.

I understand and agree that the company may deny claims and may void coverage if the company determines that any information was misrepresented on the application or any claims, subject to the Time Limit on Certain Defenses provision of the policy. If coverage is voided, the company will refund any premiums minus Application Fee and any claims paid.

The undersigned authorize release to the Company or its representatives of: all past and future medical records and other information deemed necessary by the Company to underwrite this application and to process claims.

The undersigned hereby represents that the information on this application and any other information furnished by the undersigned is complete, true and correctly recorded and acknowledge that my coverage may be terminated or rescinded for fraud or deception in the use of the policy or for materially misrepresented information in the application.

By signing and dating this application, I verify that I am a United States citizen and a legal resident of South Carolina. This Plan is not available to non-U.S. citizens or non-residents of South Carolina.

To print this agreement, please click Printable Window

Signature and Authorization

Please enter your signatures (type your name the way you would sign your name) for this application and authorization. Applicant or applicant's legal representative, please enter the information below.

Entering the information below will constitute your electronic signature on this application and authorization. The undersigned represents that the information on this application, authorization and any other information furnished by the undersigned is complete and correctly recorded.

Please note: If the applicant is a minor, a parent or legal guardian must sign.

Your relationship to the applicant:

Last 6 of Applicant's Social Security Number:

Applicant's Birth Month/Day:

Signature Date:

Payment Options

Please Select Monthly Billing or Total Payment