To apply for a Humana Health Savings Account, please fill out the following information, then call the
toll-free number listed at the bottom of this page.

• Name of Agent Writing the Policy/Agent of Record:                Wiley Long            
  
  
• Agent's Business Telephone Number:                          800-707- 9849                   
  
  
• Requested Effective Date:                                                                                              
  
  
• Requested Medical Deductible:                                                                                    
  
  
  Please make sure the following information is available for each person applying for coverage:

• Birthdate:                                                                                                                                
  
  
• SSN:                                                                                                                                       
  
  
• Height/
  Weight:                                                                                                                                  
  
  
• Current/past prescription
  medications and their dosage:                                                                                       
                                                                                                                                                   
  
  
• Medical history including diagnosis,
  treatment, dates of service and current status:                                                          
                                                                                                                                                   
                                                                                                                                                   
  
  
• Date of last Doctor office visit:                                                                                        
  
  
• Doctor's names, addresses and phone numbers:                                                    
                                                                                                                                                   
                                                                                                                                                   
  
  
• Information on current and past insurance coverage including:
  (policy number, effective dates, termination dates and phone number)
                                                                                                                                                   
                                                                                                                                                   
                                                                                                                                                   
                                                                                                                                                   
                                                                                                                                                   
  
  

PAYMENT OPTIONS:

For your convenience, the following payment options are accepted:

• For the initial payment, Humana accepts Visa, MasterCard or Automatic Check Draft.
• After the initial payment, all payments need to be made either monthly through an
  Automatic Check Draft or can be paid quarterly or semi-annually by direct bill to you
  ($10 administrative charge per direct bill).
  

Additional helpful hints:

• Application calls can generally take from 15 to 30 minutes.  However, the call can go longer
  based on the number of people applying for coverage and medical history.
  
• If applying for spousal coverage, it is necessary to have the primary applicant and their
  spouse available to authorize any requests for medical information from the Medical Information
  Bureau (when applicable).
  

                             To complete the application process, contact
                                    Humana's Application Specialists at:
                                                       1-800-211-4561