Discount Medical Plan Application
 

Plan Summary

Your plan contains the items listed below. You can click on any of the services to learn more about their specific features:

Hearing Aids

Chiropractic

Dental

TelaDoc™ with No Consultation Fee

Vision

Dining Savings

Legal Care Direct

Pharmacy Card 1

Roadside Assist


Are you interested in any of the following add on services?


 Additional Cost
LifeLock: Identity Theft Prevention - Individual $8.75
LifeLock: Identity Theft Prevention - Family $14.95

Plan Costs

Your credit card will be charged the following:

monthly fee of $29.95
one-time registration fee of $25.00

Contact Information

Your first and last name:

Your email address (for your order confirmation):

Your phone number:

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Billing Information

Please provide us with your billing address. Please make sure to provide accurate information in order to avoid processing delays.

Your street address:

Your city, state and Zip code:

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Shipping Information

Please provide us with the shipping address for this order. If your billing and shipping addresses are the same, please check the box below.

First and last name:

Shipping street address:

Shipping city, state and Zip code:

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Your Dependents

Dependent information is not required for the purchase of discount benefit plans. All family members can receive discounts using the card issued in the main member’s name. If you would like to receive additional cards reflecting the name of your dependents, please add them to the list below. Each dependent card requested will result in a one-time printing charge of $2.50 in addition to the price of your benefit purchase today. All recurring payments will be processed for the price of benefits only (when applicable).

Billing Information

Your Credit Card Number:

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We accept all major credit cards

Your Credit Card Expiration Date:

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Your credit card CV Number (what is this?):

BQARC

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If you don’t save AT LEAST $300 in just the first month, simply return the card, no questions asked. You’ll have no further obligation! Continental U.S. orders only    -    Allow 10-14 business days for delivery.