How to Apply

Application Information

This section of the HIRSP Web site offers connections to important application forms and instructions on how to complete them. The forms are in PDF format for ease of printing, we also provide an Online Application.

Individuals who want to apply for HIRSP coverage or for reductions in premium, deductible, and drug coinsurance out-of-pocket maximum may fill out these forms and submit them to HIRSP.

You can apply for HIRSP by contacting HIRSP directly or through an insurance agent licensed in Wisconsin. Parents or legal guardians may apply on behalf of dependents.

Where to Get an Application
Applications and information can be obtained from one of the following:

• HIRSP Customer Service by calling (800) 828-4777 or (608) 221-4551,
• Write to: HIRSP, P.O. Box 8961, Madison WI 53708-8961
• Your insurance agent
• The HIRSP Web site (see information below)

Save Time

If you qualify for BadgerCare Plus or Medicaid, you will be ineligible for HIRSP.
To save time, see if you qualify for Medicaid or BadgerCare Plus before applying for HIRSP.

Additional Information

• Emergency Application for Reduced Premium, Deductible, and Drug Coinsurance
  
• HIPAA Privacy Authorization for Use or Disclosure Form

Mail your completed application, payment, and relevant documentation to:

HIRSP
Attn: Member Services Administration
1751 W Broadway
PO Box 8961
Madison, WI 53708-8961

If you have questions about your application call HIRSP customer service at:

Phone:
1-800-828-4777 or 1-608-221-4551

Member Service Hours (CST):
Mon-Thurs: 7:00am - 7:00pm, Fri: 7:00am - 4:30pm

What to Submit With Your Application

Your complete and accurate application must include the following:

• A completed and signed application form for each applicant
• Proof of Wisconsin residency
• A full payment for your first quarterly premium based on the current HIRSP premium rate tables enclosed in the application packet. If you do not have a copy of the current rate tables, you may obtain one from HIRSP Customer Service. Please include a separate check for each applicant
• If applying for subsidy, include a completed Application for Reduced Premium, Deductible, and Drug Out-of Pocket Maximum
• If you are applying because of your medical condition, include copies of letters received in the past nine months from insurers for at least one of the following, based wholly or partially on medical underwriting considerations:
  • Notice of rejection from two or more insurers
  • A notice of cancellation
  • A notice of significant reduction of coverage
  • A notice of an increase in your premium of 50% or more
  • Two or more offers of insurance with premiums at least 50% higher than what would be charged for a standard individual policy with substantially the same coverage and deductibles as HIRSP
• A copy of your certificate of creditable coverage if you are applying because you lost your employer-offered group health insurance, or other forms of proof of coverage.
• A copy of your Medicare card and your Medicare Prescription