Application Forms

This section will provide you with all forms and policies needed to apply for high risk insurance with Arkansas CHIP. Applications should be mailed to CHIP Administrator, P.O. Box 1460, Little Rock, AR 72203.

These files are made available in PDF format. In order to read PDF documents, you must have Adobe Acrobat Reader installed. If you do not have the Reader installed, you may download it FREE.

• Bank Draft Form
• Claim Form
• Change Request Form

Federally/Resident Eligible

• Federal/Resident Application and Worksheet
• Policy
• Outline of Coverage
• Conditional Pre-Existing Waiver
• Policy Endorsement
• Colorectal Cancer Screening Endorsement
• HSA Endorsement (applicable only if enroll in HSA)
• Maternity Endorsement
• Wellness Care Benefits Endorsement

HCTC Eligible

• HCTC Application and Worksheet
• HCTC Policy
• HCTC Outline of Coverage
• HCTC Conditional Pre-Existing Waiver
• HCTC Policy Endorsement
• HCTC Corlorectal Cancer Screening Endorsement
• HCTC HSA endorsement (applicable only if enroll in HSA)
• HCTC Maternity Endorsement
• HCTC Wellness Care Benefits Endorsement

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