ClaimShare Cooperative Monthly Membership Request Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you were referred by another member, please name them here so we can thank them.

VEHICLE INFORMATION

Only one vehicle may be enrolled at a time. Membership benefits apply only to the vehicle submitted on this form. Please provide your vehicle information below.

Vehicle Year*

Vehicle Make*

Vehicle Model*

VIN*

What Is Your Preferred Method To Receive Electronic Paymentgs?*

PayPalZelle

Email Address For Your Preferred Method To Receive Electronic Payments*

Choose Your Membership Tier

Tier One: $250 Annual Benefit (75 Plan) Product Image

Tier One: $250 Annual Benefit (75 Plan)Provides maximum annual benefit of $250 accrued monthly.

Free for the first Five Days then, $10.50 for each month

Tier Two: $750 Annual Benefit (80 Plan) Product Image

Tier Two: $750 Annual Benefit (80 Plan)Provides maximum annual benefit of $750 accrued monthly.

Free for the first Five Days then, $31.25 for each month

Tier Three: $1,625 Annual Benefit (85 Plan) Product Image

Tier Three: $1,625 Annual Benefit (85 Plan) Provides maximum annual benefit of $1,625 accrued monthly.

Free for the first Five Days then, $67.75 for each month

Tier Four: $2,500 Annual Benefit (90 Plan) Product Image

Tier Four: $2,500 Annual Benefit (90 Plan)Provides maximum annual benefit of $2,500 accrued monthly.

Free for the first Five Days then, $104.17 for each month

EnterpriseProvides maximum annual benefit of $4,000 accrued monthly.

Free for the first Five Days then, $166.66 for each month

By selecting "Yes" below you affirm that you have read, and understand, the ClaimShare Cooperative Terms of Service found at https://claimsharecoop.com/terms-of-service*

Yes

By selecting "Yes" below you agree that monthly contributions will be automatically charged to your payment method every month until you cancel your membership.*

Yes

WHAT HAPPENS NEXT:

Once the form is submitted, we will begin processing your membership.

Your first monthly contribution will not be charged until 5 days after submission. Your plan year begins on that date.

During this time we will be setting up your account and sending you an invitation to create login access to your personalized dashboard where you can monitor all account activity including membership contributions, benefits available, and claim progress in realtime.