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 HIRSP 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 one 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 Drug card if you are Medicare eligible (if under age 65).
  • If you are applying because you lost employer-offered group health insurance:
    • Provide copies of your certificate of creditable coverage
      Note: If you are applying due to loss of employer-offered group health coverage, you do not need to submit proof of medical condition.

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

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, or by writing to:
    HIRSP, P.O. Box 8961, Madison WI 53708-8961
  • this Web page
  • Your insurance agent.