Life Care+ Membership

Life Care+ Membership

New Enrollment & Renewal Form
Enrolling in Life Care+ is easy!
1. Complete the Enrollment Form
2. Checkout & Pay for Your Membership
Member Name*

First NameLast Name
Cardholder Name (who is purchasing the membership)*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
SSN (Last 4 Digits)*

No, I am a New MemberYes, I am Renewing an Existing Membership
Membership Number*
YesNo
Primary Insurance Name*
Primary Insurance Policy/Member Number*
Primary Insurance Group Number (if applicable)
MedicareMedicaidCommercialSupplemental
YesNo
Additional Insurance Name*
Additional Insurance Policy Number*
Additional Insurance Group Number (if applicable)
MedicareMedicaidCommercialSupplemental
YesNo
Spouse's Name*

First NameLast Name
Spouse's Birthdate*

MonthDayYear
YesNo
Spouse's Insurance Name*
Spouse's Insurance Policy Number*
Spouse's Insurance Group Number (if applicable)
MedicareMedicaidCommercialSupplemental
YesNo
Dependent's Name*

First NameLast Name
Dependent's Birthdate*

MonthDayYear
Dependent's Relationship to You*
YesNo
Second Dependent's Name*

First NameLast Name
Second Dependent's Birthdate*

MonthDayYear
Second Dependent's Relationship to You*
YesNo
Third Dependent's Name*

First NameLast Name
Third Dependent's Date of Birth*

MonthDayYear
Third Dependent's Relationship to You*
YesNo
Fourth Dependent's Name*

First NameLast Name
Fourth Dependent's Birthdate*

MonthDayYear
Fourth Dependent's Relationship to You*
YesNo
Fifth Dependent's Name*

First NameLast Name
Fifth Dependent's Birthdate*

MonthDayYear
Fifth Dependent's Relationship to You*
Should be Empty: