Applications
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          Application Instructions          
Contact Information :
Walter Palmer - (612) 825-4990
Toll-Free - 1 (877) 825-4990
Cell - (612) 559-0961
FAX: (612) 825-9126
wpalmer@healthinsurancemn.com
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Thank-you for visiting the healthinsurancemn.com website and I hope that you found the information you needed. Feel free to contact me during normal business hours. I will be happy to assist you if you have any questions or if you want a quote. If you would like Applications mailed to you, I can send them to you.
Electronic Submittal Applications Available Electronic Applications
Individual Plan Change Forms
  Group Applications
 Small Group Employee Enrollment App  VIEW 
( small_group_employee.pdf )  301 Kb
 Small Group Employer Reform Application Agent-Specific  VIEW 
( small_employer_reform.pdf )  232 Kb
  Individual and Family Applications
 Insta-CareSM    Additional Page Agent-Specific  VIEW 
( instacare.pdf )  84 Kb
 Personal Blue or Options Blue 80/100 Agent-Specific  VIEW 
Additional Page                     ( Personal Blue_Options Blue.pdf )  344 Kb
 Simply BlueSM    Additional Page Agent-Specific  VIEW 
( simply_blue.pdf )  215 Kb
 SelectAccount HSA Contribution Form  VIEW 
( F7317-R09_148720.pdf )  47 Kb
 Pay-O-Matic Authorization Form  VIEW 
( F1915-R28.pdf )  139 Kb
  Medicare Applications / Forms
 Medicare Supplement/Medicare Select Agent-Specific  VIEW 
( med_sup.pdf )  367 Kb
 Medicare Platnum Blue Agent-Specific  VIEW 
( mbc1_platblue_enroll.pdf )  816 Kb
  Dental Applications
 Delta Dental for Aware Care and Personal Blue Agent-Specific  VIEW 
( aware_personalblue_dental.pdf )  225 Kb
 Dental Medicare Supplement/Select Members Agent-Specific  VIEW 
( med_sup_dental.pdf )  208 Kb
 Dental for Aware Care Members Application Agent-Specific  VIEW 
( aware_dental_app.pdf )  338 Kb
 Dental for OptionsBlue Members Application Agent-Specific  VIEW 
( optionsblue_dental.pdf )  345 Kb
 Dental for SimplyBlue Members Application Agent-Specific  VIEW 
( simplyblue_dental_app.pdf )  244 Kb
  Extra Insurance Applications
 Disability Insurance custom application from Illinois Mutual  VIEW 
( Illinois Mutual Secure Download )  239.2 Kb
  Authorization Form
 Authorization for Release of Information custom application  VIEW 
( release.pdf )  88 Kb
 Automatic Funds Transfer  VIEW 
( F6624-R8.pdf )  102 Kb
  Other Forms
 Group Employee Information Quote Form custom application  VIEW 
( group_quote_form.pdf )  73 Kb
 Individual MSA Blue Change Form Agent-Specific  VIEW 
( F7453-R8.pdf )  122 Kb
 Daycare Expense Reimbursement Claim Form  VIEW 
( F8420R03.pdf )  58 Kb
 Small Employer Group Change Form  VIEW 
( F7142-R07.pdf )  83 Kb
For Customers who are unable to open, or having difficulty opening these applications, go to: Basic Applications