Individual Forms
If you are applying for first time coverage, please visit the Certified NMHIA Agent page and select an agent in your area who can assist you in the application process This will ensure that your application is complete and will not cost you additional premium.
The Alliance provides the following Forms and Applications which can be filled out online, downloaded, and sent to the Alliance. To view these files, you will need Acrobat Reader - software that is distributed free of charge.
Electronic Funds Transfer Form - This form can be filled out online, printed and faxed to the Alliance for those individuals and groups who want their premium withdrawn from their bank account. Premium payments are withdrawn on the 1st of every month.
Individual Change Request Form - This form can be filled out on-line, printed and faxed to the Alliance for the following changes:
- Address changes
- Name changes
- Dependent additions or deletions
- Cancellation of coverage
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