PhoneThis field is for validation purposes and should be left unchanged.Newborn InformationFull Name of Baby A(Required) First Middle Last Baby A Date of Birth(Required) MM slash DD slash YYYY Baby A Birth Sex(Required)Full Name of Baby B First Middle Last Baby B Date of Birth MM slash DD slash YYYY Baby B Birth SexDelivery Hospital InformationDelivery Hospital Name(Required)Delivery Hospital Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Intended Parent InformationIntended Parent 1 Name(Required) First Last Intended Parent 2 Name First Last Intended Parent Address(Required)Please list your United States address. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Intended Parent Phone Number(Required)Please list your United States phone number.Intended Parent Email(Required) Please provide a copy of proof of birth from the hospital and/or Birth Certificate.Upload the document(s) below, or email us at submissions@arclightinsurance.com following your completion of this form. Note: Any documents are uploaded only to our secure server. Drop files here or Select files Accepted file types: jpg, png, pdf, heic, Max. file size: 50 MB, Max. files: 2. Send billing information to:Are you an agency or an individual?(Required) Agency Individual Agency Name(Required)Name(Required) First Last Email(Required)Phone Number(Required)Please review the following terms of agreement:(Required)By submitting this request, you are authorizing ArcLight Insurance to obtain a health insurance policy for the newborn(s) listed above. It is agreed that the requesting party will be charged a fee of $350 PER INSURED (BABY) for the application submission. Once this request form is received by ArcLight Insurance the above fees are fully earned. If this request is subsequently canceled on the same day as it is sent to us there will not be any fees that are due. If a cancellation request is received, all fees for services provided by ArcLight Insurance will still be due. By signing this form, you agree to the above fees. I have read the above agreement and accept the terms. I understand that ArcLight will only provide services after payment is received.Signee Full Name(Required) First Last Please re-print your name, your "Electronic Signature" below:(Required)Date(Required) MM slash DD slash YYYY Please leave any additional comments or instructions here: Δ
