G3 PREM 1 of 2

Discount Medical Plan Application
Member Information

PREMIER PLUS $19.95 Monthly + One-Time Registration of $6.95
Discount Code if Available:
Name

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Gender
Birth Date:

MonthDayYear
Language
E-mail
Dependent information is not required for the purchase of discount benefit plans. All legal dependents can receive discounts using the card issued in the main member’s name. If you would like to receive additional cards reflecting the name of your dependents, please first select the appropriate number of dependents and then list their information below. Each dependent card requested will result in a one-time printing charge in addition to the price of your benefit purchase today. All recurring payments will be processed for the price of benefits only (when applicable).
Form G3_PREM_1OF2_3.15
Should be Empty:

Member Information