Appendix A- Comprehensive Health Insurance Risk Pool Association Notice Form

Appendix A- Comprehensive Health Insurance Risk Pool Association Notice Form APPENDIX A Comprehensive Health Insurance Risk Pool Association Notice Form Date Name Address City, State Zip Code RE: Applicant/Insured’s Name Policy # (if applicable) Dear __________________: We believe that you may qualify for health insurance from the Mississippi Comprehensive Health Insurance Risk Pool Association (the “Association”). This insurance is available to Mississippi residents who, because of health conditions, cannot secure health insurance coverage substantially similar to the Association plan coverage without material underwriting restrictions at a rate equal to or less than the Association plan rate. Other eligibility requirements, exclusions and limitations may apply. You may apply to the Association for a determination of your eligibility for insurance on application forms available from the Association. For more information regarding the Association go to www.mississippihealthpool.org or contact the Association at: Mississippi Comprehensive Health Insurance Risk Pool Association Post Office Box 13748 Jackson, MS 39236-3748 888-820-9400 Insurance Company Name Address Contact Person Phone Number