(It may be a good idea to print this page to have on hand while working on your application!)
1. USE ONLY BLACK INK (ball point is best) – DO NOT USE WHITEOUT!!!!
(If you make an error draw a single line through it and initial correction,
or if you prefer, print that page again!)
2. Fill in all applicable spaces as completely and accurately as possible
3. Use extra sheet of paper if needed for health info details (sign & date it)
4. Be sure to sign and date application
5. Complete and sign Bank Draft form if choosing monthly bank draft
6. Attach a voided check if choosing bank draft
8. Call me at 1-888-601-8020 with any questions anytime*
(*Usual hours are from 8 am-7:30 pm Mon-Fri, 8 am-12 Sat)
9.Mail to Life and Health Plus - Not to Insurance Company!!
Please mail to:
Life and Health Plus
2950 W Lucas Dr
Beaumont, TX 77706-7817
ATTENTION! The latest version of Adobe Acrobat Reader
(6.0) is required - you may download it free here:
The Golden Rule applications can be completed on your computer after opening the files, just open, double click your mouse in the first blank, and type in your info. Then print out, sign the application, and mail it to Life and Health Plus!
Golden Rule - ARKANSAS Golden Rule - TEXAS
(Payment required with application)
The Celtic, Emergency Medical Plan,and UniCare Major Med applications must be printed out and then completed by hand, then mailed to Life and Health Plus! The Celtic plan can be done online here and the UniCare plan can be done online here.
Celtic - ARKANSAS Celtic - TEXAS
(Payment required with application)
(Payment required with application)
UniCare Application UniCare Replacement Form
(Payment required with application)
United Security Life APEX Plan
(Payment required with application)
United Security Life Protector Plus Plan
(Payment required with application)
Now choose and get your application: (some may be slow to open, please be patient)
Remember! Mail to Life and Health Plus - Not to Insurance Company!!
Please mail to:
Life and Health Plus
2950 W Lucas Dr
Beaumont, TX 77706-7817
To return home Close This Window