Enrollment Form

Questions? Please contact Janet Salyer, jsalyer@insuranceplanningsolutions.com or 678-880-6399

Home address

Mailing address


Coverage to be Enrolled In

Premiums vary per person and are based your age and wages.
Please contact Janet Salyer for your disability rates. The disability coverage is for employees only.

If $25,000, $50,000, $100,000 options are selected, indicate the following:

Enrolling in coverage

Add a Dependent

Insurance Planning Solutions, Inc. (IPS) is committed to protecting the privacy of the users of this website. (We will use and disclose the information you provide us as stated in this Privacy Statement.)

Website and Mobile privacy statement
Use and disclosure of health information includes using the information to provide treatment to the individual, to make payments for such treatment, and to conduct ongoing quality improvement activities. Our use and disclosure of an individual's personal information (including health information) is limited as required by state and federal law. We do not sell or rent personal information about visitors to this site or customers who use the site.

This website and the has security measures in place to help protect against the loss, misuse, or alteration of information under our control. These measures include encryption of data using the Secure Socket Layer (SSL) system, and using a secured messaging service when we send you personal information electronically. Despite these measures, the confidentiality of any communication or material transmitted to or from us via this site or by Internet or email cannot be guaranteed. At your discretion, you may contact us at the mailing address or telephone number listed in the "Questions, complaints, and contacts" section at the end of this Privacy Statement.

Revisions to the Privacy Statement
We may revise this Privacy Statement from time to time as we add new features or as laws change that may affect our services. If we make material changes to our Privacy Statement, we will post notice of this on our website. Any revised Privacy Statement will apply both to information we already have about you at the time of the change, and any personal information created or received after the change takes effect. We include a version number on this Privacy Statement consisting of the date (year, month, and day) it was last revised. We encourage you to periodically reread this Privacy Statement, to see if there have been any changes to our policies that may affect you.

Website visitor data
Insurance Planning Solutions Inc routinely gathers data on website activity, such as how many people visit the site, the web pages where they come from, how long they stay, etc. The data is collected on an aggregate, anonymous basis, which means that no personally identifiable information is associated with the data. This data helps us improve our content and overall usage. The information is not shared with other organizations for their independent use.

Data caching by mobile applications
Insurance Planning Solutions, Inc does not currently utilize mobile applications. This is subject to possible future change and the Privacy Policy will be updated to include Mobile applications

Collecting and using personal information
Except as disclosed in this Privacy Statement, we do not collect any identifiable information about visitors to this site or the KP Mobile Applications. The policies, sources, and uses of information are outlined in Sections 1 through 13 that follow:

1. Web logs
We maintain standard Web logs that record data about all visitors and customers who use this site and we store this information for a while. These logs may contain the Internet domain from which you access the site (such as aol.com, abc.org, etc.); the IP address which is automatically assigned to your computer when you get on the Internet (a static IP address may be identifiable as being connected to you, while a dynamic address is usually not identifiable); the type of browser and operating system you use; the date and time you visited; the pages or mobile screens you viewed; and the address of the website you linked from, if any. If you sign on to this website to use secured features, our Web logs will also contain an individual identifier and show the services you have accessed.

All Web logs are stored securely, and may only be accessed by Insurance Planning Solutions, Inc. employees or designees on a need-to-know basis for a specific purpose. IPS uses Web log information to help us design our site and, to identify popular features, to resolve user, hardware, and software problems, and to make the site more useful to visitors.

2. Internet cookies
We may place Internet "cookies" on the computer hard drives of visitors to this Insurance Planning Solutions, Inc. website. Information we obtain from cookies helps us to tailor our site to be more helpful and efficient for our visitors. The cookie consists of a unique identifier that does not contain information about you or your health history. We use two types of cookies, "session" cookies and "persistent" cookies.

A session cookie is temporary, and expires after you end a session and close your web browser. We use session cookies to help customize your experience on our site, maintain your signed-on status as you navigate through our features, and to track your "click path" through our Web pages or mobile screens.

Persistent cookies remain on your hard drive after you've exited from our website, and we use them for several reasons. For instance, when you give us permission to "remember" a feature about you when asked by the website, such as your location, we place a persistent cookie on your hard drive so that the next time you visit us, we won't have to ask you that information again. If you've given us permission to email you with information about your Insurance Planning Solutions benefits, or for other reasons, we may place a persistent cookie on your hard drive that will let us know when you come back to visit our site. We sometimes use this type of persistent cookie with a "Web beacon" (see below). Persistent cookies will not contain any personal information about you such as Health/Medical Record number.

You may have software on your computer that will allow you to decline or deactivate Internet cookies, but if you do so, some features of this site may not work properly for you. For instructions on how to remove cookies from your hard drive, go to your browser's website for detailed instructions. In addition, further information regarding cookies may be available on other websites or from your Internet service provider. Safari, Chrome, Firefox, Internet Explorer and iOS browsers are commonly used browsers.

3. Web beacons
We may also occasionally use "Web beacons" (also known as "clear gifs," "Web bugs," "1-pixel gifs," etc.) that allow us to collect non-personal information about your response to our email communications, and for other purposes. Web beacons are tiny images, placed on a Web page or email, that can tell us if you've gone to a particular area on our website. For example, if you've given us permission to send you emails, we may send you an email urging you to use a certain feature on our website. If you do respond to that email and use that feature, the Web beacon will tell us that our email communication with you has been successful. We do not collect any personal health information with a Web beacon, and do not link Web beacons with any other personal health information you've given us.

Since Web beacons are used in conjunction with persistent cookies (described above), if you set your browser to decline or deactivate cookies, Web beacons cannot function.

4. Emails
Insurance Planning Solutions, Inc. uses a third-party vendor to help us manage some of our email communications with you. While we do supply this vendor with email addresses of those we wish them to contact, your email address is never used for any purpose other than to communicate with you on our behalf. When you click on a link in an email, you may temporarily be redirected through one of the vendor's servers (although this process will be invisible to you) which will register that you've clicked on that link, and have visited our website. Insurance Planning Solutions, Inc. never shares any information, other than your email address, with our third-party email vendor, which does not share these email addresses with anyone else.
Even if you have given us permission to send emails to you, you may revoke that permission at any time by following the "unsubscribe" information at the bottom of the email.

5. Evaluation and research
We will periodically ask users to complete surveys asking about their experiences with features of the website. Our surveys ask visitors for demographic information such as age, gender, and education, but will not request that users provide specific information about any medical condition. We use survey information for research and quality improvement purposes, including helping Insurance Planning Solutions, Inc. to improve information and services offered through the website. In addition, users giving feedback may be individually contacted for follow-up due to concerns raised during the course of such evaluation. Demographic information and Web log data may be stored for future research and evaluation.

6. Application for Plan membership
If you apply with Insurance Planning Solutions, Inc. for any medical, dental, disability or other plan, through this website, you will be asked during the application process to disclose certain personal information so that we can evaluate your eligibility. Specifically, you will be asked to provide demographic information (name, address, other contact information and age), answer questions regarding your medical history and current health status, and verify the truthfulness of your answers.

7. Messages and transactions
Comments or questions sent to us using email or secure messaging forms will be shared with Insurance Planning Solutions, Inc. staff and health care professionals who are most able to address your concerns. We will archive your messages once we have made our best effort to provide you with a complete and satisfactory response.

9. Data integrity and correction
Requests to view and correct personal information from this website that is documented in your data entry may be submitted using the contact information in the "Questions, complaints, and contacts" section below (when available).

10. Children
We do not knowingly allow Insurance Planning Solutions, Inc. group plan members under the age of 13 to create accounts that allow access to the secured features of this site

11. Disclosures
We may disclose personal information to any person performing audit, legal, operational, or other services for us. We will use information which does not identify the individual for these activities whenever feasible. Information disclosed to vendors or contractors for operational purposes may not be re-disclosed to others by such a vendor or contractor.
We may disclose personal information when required to do so by a subpoena, court order, or search warrant. We may disclose personal information as we deem it appropriate to protect the safety of an individual or for an investigation related to public safety or to report an activity that appears to be in violation of law. We may disclose personal information to protect the security and reliability of this site, and to take precautions against liability.

12. Opt out
If a user makes a request to receive information in an ongoing manner through this website by providing their email address (for example, requesting a subscription to one of our online publications), a user may make a request to discontinue future mailings. Similarly, if you receive information about one of our services through email, you may make a request to discontinue receiving similar messages in the future. All such materials sent to you by email will contain information about how to opt out.

Also, if as a member you register to use protected features on our website, you may be given an opportunity to receive emails about different types of IPS products, services, announcements, and updates. On our website, you may change your preferences per instructions to be added at a future time.

13. Other requests to limit use and disclosure of your personal information
State and federal laws may allow you to request that we limit our uses and disclosures of your personal information for treatment, payment, and health care operations purposes. However, by law, we do not have to agree to your request. It is our policy not to agree to requests for restrictions beyond what is described in the "Opt out" section above.

Questions, complaints, and contacts
If you have any questions about this Privacy Statement, our policies and practices concerning this site your rights under this statement, and your dealings with the Insurance Planning Solutions, Inc. website, you can contact IPS by telephone at 678-880-7098, by sending a message to the IPS Web manager, or by U.S. mail at the address below:

Insurance Planning Solutions, Inc.
138 Misty Valley Drive, Canton, GA 30114
Last revised January 8, 2014

Questions? Please contact Janet Salyer, jsalyer@insuranceplanningsolutions.com or 678-880-6399