Group Insurance Enrollment | The Healing Place SC

Fields marked * are required. No payment is collected here.

Applicant Details

Full name *Date of birth *Social Security number *

Phone *Email *

Street address *

City *State *ZIP *

Sex *Marital status *

Employment status *OccupationDo you use tobacco? *Group eligibility *

Family Members

Add each spouse or child who may need coverage.

Required Coverage: Choose At Least Two

You must select at least two of these three products to participate in this group.

Choose 2 more to continue.

Life Insurance

Pays a benefit to your beneficiary if you die while covered.

View / Download GTL100 Underwriting Definitions & Benefits (The Standard)View / Download Group Term To Age 100 Life Insurance (GPTLC) — Rate Sheet

Critical Illness/Cancer

Pays benefits for covered serious conditions, including certain cancers, heart attack, and stroke.

View / Download Critical Illness — Benefits & Premiums (The Standard)

Supplemental Coverage

Pays set benefits for covered hospital stays, surgery, and other health services.

View / Download Group Supplemental Health (GVSP1) — Allstate Benefits

Available rate sheets are for reference. Your final premium and eligibility will be confirmed before payment setup.

Additional Coverage

Choose any additional products. Your preferences guide plan recommendations; benefits depend on the plan.

Major Medical

Dental

Vision

Contact Preferences

Preferred contact methodBest time to contact youQuestions or notes

Payment Responsibility

Choose your regular schedule *Half on the 1st and half on the 15thFull premium on the 1stFull premium on the 15th

I understand that submitting this enrollment form does not make a payment.I understand that my first payment will draft on October 15, 2026, provided I have accepted my final premium and completed ACH authorization.I understand that no payment is scheduled until both steps are complete.I agree to pay my full insurance premium. The church will not pay my premium for me.

These acknowledgments do not authorize ACH. Any processing fee will be disclosed before you authorize payment.

Consent And Signature

I authorize The Healing Place SC and the insurance provider to contact me by phone, text, or email about this insurance application. I understand additional information may be needed before coverage can be issued.Type your full name as your electronic signature *

Your signature date and time will be recorded on submission.

Questions about your coverage? Contact the insurance provider at 803-661-6939.