Get an Enrollment Form - apply via secure webpage, mail, or fax

If an online application isn't for you, a paper application or a fax application can be sent to you via U.S. Postal Service or via fax. We can also send you an electronic form via email. All of these documents will need to be returned to our office for counter-signature before submission. Coverage will take effect when your completed application and full premium payment are received by Time Insurance Company, Assurant Health.

To request an Short Term Medical enrollment form, email me with your name and postal address or email address, or a fax number, and I will provide you with an STM brochure/application to review and complete.

We recommend you get a quote and apply via our secure Assurant Health website. Fast, safe, and convenient, you can be covered as early as the next day!