USAway Major Medical Insurance

Applicant

# of Applicants

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I hereby confirm that the individuals listed above are not part of an Employer Group.

Effective Date mm/dd/yyyy

Expiry Date mm/dd/yyyy

THIS IS NOT QUALIFYING HEALTH COVERAGE ("MINIMUM ESSENTIAL COVERAGE") THAT SATISFIES THE HEALTH COVERAGE REQUIREMENT OF THE AFFORDABLE CARE ACT. IF YOU DON'T HAVE MINIMUM ESSENTIAL COVERAGE, YOU MAY OWE AN ADDITIONAL PAYMENT WITH YOUR TAXES.

This plan does not cover pre-existing conditions.

This plan does not cover preventative care.

Coverage is NOT available online in the following countries: Afghanistan, Belarus, Cuba, Iran, Israel (Excluding Gaza Strip And West Bank), Israel - Gaza Strip Only, Israel - West Bank Only, North Korea, Russia, Sudan, and Ukraine

Coverage cannot be purchased in the following states: AK, CO, CT, DE, GU, IA, IL, KY, MD, ME, MO, MS, MT, NC, NE, NJ, NM, NY, OR, RI, SC, SD, TN

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CA License #: 0591207