UNDERWRITTEN BY CELTIC INSURANCE COMPANY, CHICAGO, IL
If child-only coverage is being requested, the child is the primary applicant and a separate application must be completed for each child.
Requested Effective Date:
NOTE: the 29, 30 and 31 of the month are not
eligible as effective dates. Application is valid
within 60 days from the signature date.
Social Security Number:
Guardian’s Name: (with whom the child resides):
GUARDIAN INFORMATION (For Applicants under 18 years of age):
Primary Applicant’s Name:
SECTION 1: GENERAL INFORMATION
Please print in inkPlease check if this application is for:
New Applicant Add Dependent
Plan Change Reapply
Sex: Male Female
Marital Status: Single Married Divorced Widowed
Name and Billing Address:
Home Phone Number: Phone Number during regular business hours: Occupation: ( Position and Type of Business)
( ) ( )
BILLING INFORMATION If different from Applicant’s Home Address (Please send bills to):
Is each of the following Applicants to be insured a U.S. citizen or a permanent legal resident of the U.S. for the last
Primary applicant: Yes No* Spouse: Yes No* Dependent(s): Yes No*
* If “No,” coverage cannot be granted for that applicant.
Does the payor want to include other family members on one billing statement? Yes No
If “Yes,” the Family Billing Statement Form needs to be completed, dated, signed and submitted with the application.
CELTIC INSURANCE COMPANY
Have you and/or any dependent to be covered previously applied for insurance with Celtic Insurance Company?
Yes No If “Yes,” provide policy or certificate # _________________________