Brokers

Partner With Citadel One Health

Help your clients access flexible healthcare benefit solutions through Citadel One Health. Our programs provide additional healthcare support, savings opportunities, and member resources designed to meet different needs.

Become A Broker

Getting Started Is Simple

Step 1

Submit Your Information

Complete the broker inquiry form and share your details.

Step 2

Connect With Our Team

Our team will review your request and provide next steps.

Step 3

Start Supporting Clients

Access available resources and begin offering benefit solutions.

Interested In Becoming A Broker Partner?

Life and Health - Application

Please complete all required sections to apply for your health plan. All information is confidential and used for underwriting and eligibility purposes.

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Application Details

Application Type*

New Application

Policy Changes

Requested Effective Date*

Policy Change

Add or Delete an Insured

Add or Change Benefits

Policy Number

Policy Type*

Individual

Group

Primary Applicant

Primary Applicant Name*

First Last

Phone Number*

Email*

Applicant's Physical Address (No P.O. Box)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender*

Male

Female

Date of Birth*

Tobacco User?*

Yes

No

Age

Government Issued ID (Required)*

Height*

Weight (lbs)*

Birth State*

Primary Applicant's Occupation or Job Description*

Premium Payor (Group or Company Information)

Group or Company Name

Group or Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employment Start Date

Spouse

Spouse Name

First Name Middle Name Last Name

Gender

Male

Female

Date of Birth

Age

Government Issued ID (Spouse)

Height (ft/in)

Weight (lbs)

Tobacco User?

Yes

No

Birth State

Spouse's Occupation or Job Description

Children

Children Information

Child Name

Relationship to Applicant

Government Issued ID

Gender

Age

Birth State

Height (ft/in)

Weight (lbs)

Date of Birth

Continue

Add Another Child

Health Questionnaire

Health Questions (1-25)

Please answer Yes or No for each question.

1. In the past 10 years, diagnosis/treatment for major illnesses: Liver cirrhosis, Hepatitis B, insulin-dependent/diabetes and/or neuropathy, ulcerative colitis or Crohn's, Down's Syndrome, intellectual disability, Autism, Rheumatoid Arthritis, ALS (Lou Gehrig's Disease), Alzheimer's, Parkinson's, Dementia, Cystic fibrosis, heart attack, coronary bypass, coronary artery disease, Congestive Heart Failure, cerebral palsy, sickle cell or aplastic anemia, leukemia, transplant recipient, multiple sclerosis, muscular dystrophy, lupus, COPD, sudden apnea, Stroke or TIA, paraplegia or quadriplegia, kidney or renal failure, or been hospitalized more than 3 times in the past year?*

Yes

No

2. Diagnosis/treatment for AIDS/ARC in 10 years?*

Yes

No

3. Any applicant currently pregnant or pending adoption?*

Yes

No

4. In past 5 years, diagnosis/treatment for cancer or malignancy?*

Yes

No

5. In past 12 months, abnormal lab tests (PSA, CEA, mammogram, etc.)?*

Yes

No

6. In past 4 years, diagnosis/treatment for drug/alcohol abuse?*

Yes

No

7. In past 6 months, confined to nursing facility/disabled?*

Yes

No

8. Intend to reside outside US?*

Yes

No

9. Tobacco/nicotine use in past 24 months?*

Yes

No

10. Hazardous sports/activities in past 12 months?*

Yes

No

11. Diagnosis/treatment for back/neck/joint injury in 12 months?*

Yes

No

12. In 12 months, diagnosis/treatment for listed chronic conditions?*

Yes

No

13. Cesarean section/miscarriage/infertility (women)?*

Yes

No

14. In 12 months, diagnosis/treatment for other listed conditions?*

Yes

No

15. Medical/surgical advice or tests recommended but not completed?*

Yes

No

16. Covid-19 diagnosis/hospitalization in 12 months?*

Yes

No

17. Drug/alcohol abuse treatment in 3 years?*

Yes

No

18. Back/neck/joint injury in 12 months?*

Yes

No

19. Heart valve/arrhythmia diagnosis in 2 years?*

Yes

No

20. Hospitalized more than 2 times in 12 months?*

Yes

No

21. Abnormal test/treatment in 12 months?*

Yes

No

22. Diagnosis/treatment for arthritis or bone/joint disease in 10 years?*

Yes

No

23. Diagnosis/treatment for heart/circulatory disease in 10 years?*

Yes

No

24. Other health/accident/disability insurance in force?*

Yes

No

25. Applicants 19-26 full time students?*

Yes

No

Are all applicants at or below weight limit for their respective height?*

Yes

No

Weight Limit Acknowledgement*

I acknowledge that I have read the weight limit table and understand other coverage options may be available.

Explanations for Yes answers (Questions 1-19)

Explanations

Applicant

Surgery Performed?

Yes

No

Hospitalized?

Yes

No

Nature of Illness or Accident

Date Started

Date Ended

Hospitalization Date Started

Hospitalization Date Ended

Physician Name

Physician Phone Number

Physician's Address

Explanations

Add Explanations

Current Insurance Information

Current Insurance - Company Name

Type of Insurance

Current Insurance - Company Name (2)

Type of Insurance (2)

Will the insurance applied for replace any existing insurance?*

Yes

No

Beneficiaries

Primary Beneficiary*

Primary Relationship*

Secondary Beneficiary

Secondary Relationship

Billing

Underwriting Fee Acknowledgement*

I acknowledge the non-refundable underwriting fee.

How will your policy be billed?*

Individual

Group or Company

Billing Method*

Monthly ACH

Name on Account*

Name of Bank

Are you Authorized Signer for billing?*

Yes

No

Primary Applicant Signature