ClaimShare Cooperative Annual Membership Request Form

Annual Membership Request Form

Annually Paying Members Enjoy a 10% Discount on Their Contribution
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*
example@example.com

Choose Your Membership Tier*

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)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) 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)Provides maximum annual benefit of $2,500 available immediately.

Free for the first Five Days then, $1,125.00 for each year

EnterpriseProvides maximum annual benefit of $4,000 available immediately.

Free for the first Five Days then, $1,800.00 for each year

Enterprise UnlimitedProvides unlimited annual benefits available immediately.

Free for the first Five Days then, $3,750.00 for each year

Enter coupon

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 annual contributions will be automatically charged to your payment method on your plan year end date, to renew for another year, unless and until you cancel your membership.*

Yes
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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