Celtic Basic Application
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.
Place of Birth: (Country)
Social Security Number:
Guardian’s Name: (with whom the child resides): Relationship to Child Social Security Number:
GUARDIAN INFORMATION (For Applicants under 18 years of age):
Primary Applicant’s Name:
SECTION 1: GENERAL INFORMATION
Please print in inkAuthorization Code:
(If QuikCoverage was requested)
Please 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):
Are the following Applicants to be insured U.S. citizens?
Primary applicant: Yes No* Spouse: Yes No* Dependent(s): Yes No*
*If anyone answered “No,” to the above question, please indicate if he or she has been a permanent legal resident
of the U.S. for the last two years?
Primary applicant: Yes No** Spouse: Yes No** Dependent(s): Yes No**
** If “No,” coverage cannot be granted for that applicant.
CELTIC INSURANCE COMPANY
Have you and/or an