About You | The American Bar Association

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Member Information

All fields are required unless mentioned as optional

First Name

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MI (optional)

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Last Name

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Street Address

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City

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State

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ZIP Code

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This coverage is not available within your state.

To learn more, contact USI Affinity at  855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com

Primary Phone Number

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Date of Birth MM/DD/YYYY

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Sex Assigned at Birth

Male
Female

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Email Address

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Do you currently have basic health insurance coverage?

Yes
No

Error: Please indicate if member has Active MEC.

Within the last 12 months, have you used tobacco or nicotine in any form?

Yes
No

Error: Please indicate if Member is a Smoker.

Would you like to add family members to your coverage? (optional)

To enroll your Spouse and Child(ren), simply check both boxes. This ensures that all relevant family members are covered under the plan.

Spouse

Dependent Children

Spouse Information

First Name

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Last Name

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Middle Initial

Date of Birth

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Sex Assigned at Birth

Male
Female

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Primary Phone Number

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Use Different Address

Address

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City

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State

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Zip Code

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This coverage is not available due to {SpouseFirstName}'s age requirements of this plan.

To learn more, contact USI Affinity at 855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com

Does your spouse currently have basic health insurance coverage?

Yes
No

Error: Please indicate if your spouse has active MEC

Within the last 12 months, have you used tobacco or nicotine in any form?

Yes
No

Error: Please indicate if your spouse is a smoker

Children Information

How many children 24 years old or younger are you insuring?

Error: Please Select Number of Children

By continuing, you confirm your child is 25 or younger.

This helps us ensure they receive the right coverage for their age group.

First Name

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Last Name

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Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

First Name

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Last Name

Error: Last name is required

Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

First Name

Error: First name is required

Last Name

Error: Last name is required

Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

First Name

Error: First name is required

Last Name

Error: Last name is required

Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

First Name

Error: First name is required

Last Name

Error: Last name is required

Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

First Name

Error: First name is required

Last Name

Error: Last name is required

Date of Birth

Error: A valid birth date (25 or younger) is required

Sex Assigned at Birth

Male
Female

Error: Sex assigned at birth is required

To add more children to your policy after enrollment, contact USI Affinity at 855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com.

This coverage is not available due to children age requirements of this plan.

To learn more, contact USI Affinity at 855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com.

Do your child(ren) currently have basic health insurance coverage?

Yes
No

Error: A valid selection must be supplied

This coverage is not available due to requirements of this plan.

To learn more, contact USI Affinity at  855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com

This coverage is not available due to requirements of this plan.

To learn more, contact USI Affinity at  855-874-0262, weekdays from 8am to 6pm EST or IB.NewBusiness@usi.com

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