Date Of Birth

Effective Date

Plan Information

Single ( $24.95 per month )
Family ( $29.95 per month )

Payment Information to be provided if your plan is not payroll deduct

American Express
Marketing Representative:

Monthly payment is always processed in advanced on the 25th of each month. Initial payment will be secured within 72 hours of enrollment. If payment is not received on the date billed a letter is sent to the cardholder advising we are unable to collect payment and they must contact our office. If payment is not received by the last date of the month the cardholder will become inactive until the account is brought current. A notice of termination is sent to the cardholder. Cardholders have 60 days to reinstate the benefits with payment. The information and description are not intended to be complete description of all terms, exclusions, and conditions applicable to the products and services. The specific rates terms and conditions of benefits will be based on actual program selected. A one-time fee of $2.00 for processing and fulfillment will be add to your first payment.