YOUR Information
*First Name
*Last Name
*E-mail Address
New Member Information
(If you are enrolling yourself, re-enter
your info)
*First Name:
Middle Initial:
*Last Name:
*Date of Birth:
(MMDDYYYY)
*Sex:
FEM
MALE
*S.S. Number:
(000-00-0000)
*Street Address:
Address (conts.):
*City:
*State:
If new member lives in Canada please put
Canada
AL
AK
AZ
AR
CA
CANADA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Zip Code:
*Home Phone:
(000-000-0000)
E-mail:
Marital Status:
Single
Married
Separated
Widowed
If there is no spouse leave the next two fields blank
Spouse/Other Phone:
(000-000-0000)
Spouse/Other S.S.N.:
(000-00-0000)
Nearest living relative not residing
with member
Name:
Relationship:
Phone:
(000-000-0000)
Please
provide the following employment information
(IF NOT
CURRENTLY EMPLOYED - JUST LEAVE THESE FIELDS BLANK)
Organization:
Occupation:
Street Address:
Address (cont.):
City:
State:
If employment is in Canada, please select "CANADA"
AL
AK
AZ
AR
CA
CANADA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
Work Phone:
(000-000-0000)
Please provide the following dependents information
(IF NO
DEPENDENTS -JUST LEAVE THESE FIELDS BLANK)
# of dependents:
0
1
2
3
4
5
6
7
8
9
10
Name:
Sex:
Birthdate:(MMDDYYYY)
Fulltime Student?
Spouse/Other:
FEM
MALE
YES
NO
Dependent 1:
FEM
MALE
YES
NO
Dependent 2:
FEM
MALE
YES
NO
Dependent 3:
FEM
MALE
YES
NO
Dependent 4:
FEM
MALE
YES
NO
Please add any additional dependents here:
(MAKE SURE TO INCLUDE FULL NAME, SEX, DATE OF BIRTH, and STUDENT STATUS)
Please provide the following ordering information:
THIS INFORMATION IS ESSENTIAL. PLEASE DOUBLE CHECK THAT YOU HAVE
ENTERED THE INFORMATION CORRECTLY.
Billing
*Checkholder Name:
Secondary Name:
*Bank Name:
*Bank City:
*Bank State:
If bank is in CANADA,
please select "CANADA"
AL
AK
AZ
AR
CA
CANADA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*Bank Zip Code:
*Bank Phone:
(000-000-0000)
*Check Number:
*MICR Numbers:
Routing Number
Account
Number
Check Number (9 Digits)
:|
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Program Choices:
Basic Program: $14.95/month:
(includes dental, prescription, vision and legal benefits. If you ar going to be a new
Associate and are enrolling your own family in the membership card, the Basic Program is
only $9.95/month, which is 1/3rd off the retail price!)
Add-ons:Physician (Basic Program plus $5.00/month)
Initial Set-Up Fee:
$19.95 (For a limited time only! Normally $29.95)
Please choose ONE of the following:
Associate Rates:
Consumer Rates:
$14.95 (Including Physician services)
$9.95 (excluding
Physician services)
$19.95 (including Physician services)
$14.95
(exluding Physician services)
NEW! Annual
Discounted Rates (Save up to $90!!!)
$99
(excluding Physician services)
$149 (including Physician services)
All monthly enrollments include: Initial Set-Up Fee + First Month and are electronically processed within 48 hours.
All company refund policies apply.
There is a $10.00 administrative and processing fee for Insufficient funds and returned checks.