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  Consumer Information Request Form
 
Maine Clients 
New Hampshire Clients 
FAQ for STM 
Travel Medical Plans 
If you need temporary coverage and are from  Maine or New Hampshire, applications and descriptions of coverage are available. If you would like information for a permanent solution to your health care needs please complete the form below. If you don't know what plan is appropriate, use the FAQ link to help answer your questions. 

Please complete this form and we will assist you with health insurance needs.

Please provide the following  information:

Name
Street address
Address (cont.)
City
State
Zip/Postal code
Work Phone
Home Phone
E-mail

Help us prepare the right information for you, please describe yourself:

Date of birth
Marital Status Single Married
Are you a citizen of the U.S? Yes No
Do you currently have health insurance? Yes No
Ask any specific questions below:

Last revised: July 09, 2008