CYA Risk Management Enrollment form

1

Will member electronically sign?

YESNO

2

Sales Rep Name* This field is required.

First Name

Last Name

3

Sales Rep Email* This field is required.

example@example.com

4

Sales Rep Phone Number* This field is required.

Please enter a valid phone number.

5

Name* This field is required.

First Name

Last Name

6

Gender

Male

Female

7

Date of Birth

8

Email* This field is required.

example@example.com

9

Phone* This field is required.

10

Street Address* This field is required.

11

City* This field is required.

12

State* This field is required.

13

Zip Code* This field is required.

14

Are you covering a family member?* This field is required.

YESNO

15

Name

First Name

Last Name

16

DOB

17

Relation

18

Gender

19

Name

First Name

Last Name

20

DOB

21

Relation

22

Gender

23

Name

First Name

Last Name

24

DOB

25

Relation

26

Gender

27

Name

First Name

Last Name

28

DOB

29

Relation

30

Gender

31

Name

First Name

Last Name

32

DOB

33

Relation

34

Gender

35

Name

First Name

Last Name

36

DOB

37

Relation

38

Gender

39

Name

First Name

Last Name

40

DOB

41

Relation

42

Gender

43

Select Product* This field is required.

DPC365 Plus

DPC365 Elite

44

DPC365 Plus

Individual

Member/Spouse

Member Child/Children

Family

45

DPC365 Elite

Individual

Member/Spouse

Member Child/Children

Family

46

Payment Amount* This field is required.

47

Payment Start Date* This field is required.

Date

48

Billing Contact Name* This field is required.

49

Billing Street Address* This field is required.

50

City* This field is required.

51

State* This field is required.

52

Zip Code* This field is required.

53

Payment Method* This field is required.

ACH

Debit/Credit Card

54

Bank Account Type

Checking

Savings

55

Routing

56

Account

57

Card Number

58

Expiration Date

59

CVV

60

Signature of Responsible Party* This field is required.Authorization: I hereby authorize CYA Risk Management to initiate recurring payments as indicated above. I understand that this authorization will remain in effect until I cancel it in writing with a 30 day notice.

61

Enrolled over phone

62

Date* This field is required.

Date