• Annual Membership Request Form

    Annually Paying Members Enjoy a 10% Discount on Their Contribution
  • 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.

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    Tier One: $250 Annual Benefit (75 Plan) Product Image
    Tier One: $250 Annual Benefit (75 Plan)Provides maximum annual benefit of $250 available immediately.
    Free for the first Five Days then, $113.40 for each year
      
    Tier Two: $750 Annual Benefit (80 Plan) Product Image
    Tier Two: $750 Annual Benefit (80 Plan)Provides maximum annual benefit of $750 available immediately.
    Free for the first Five Days then, $337.50 for each year
      
    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 available immediately.
    Free for the first Five Days then, $731.70 for each year
      
    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 available immediately.
    Free for the first Five Days then, $1,125.00 for each year
      
    Enterprise Product Image
    EnterpriseProvides maximum annual benefit of $4,000 available immediately.
    Free for the first Five Days then, $1,800.00 for each year
      
    Enterprise Unlimited Product Image
    Enterprise UnlimitedProvides unlimited annual benefits available immediately.
    Free for the first Five Days then, $3,750.00 for each year
      
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  • WHAT HAPPENS NEXT:

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

    Your first annual 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.

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