Enrollment Form
*
REQUIRED
Date of Birth
*
Example: MM/DD/YYY
First Name:
*
Last Name:
Middle Initial:
*
Sex:
MALE
FEMALE
Home Phone:
*
Email:
Example: ###-###-####
Home Address:
*
City:
*
State:
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
WASHINGTON DC
DELAWARE
FLORIDA
GEORGIA
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
*
Zip
Work Phone:
Beneficiary:
Extension:
Relationship:
WIFE
HUSBAND
SON
DAUGHTER
FATHER
MOTHER
BROTHER
SISTER
OTHER
Preferred Language:
ENGLISH
SPANISH
PORTUGUESE
CHINESE
KOREAN
VIETAMESE
OTHER
Check here if your mailing address is different from your credit card billing address.
Spouse:
Sex:
MALE
FEMALE
Date of Birth:
Example: MM/DD/YYYY
Please Note: If child is age 19-24, he/she must be a full-time student and/or an IRS dependent. If you have more than 5 dependents : Fax the complete list of dependents along with the Name, Complete Address and Social Security of the Applicant to 858-459-8237
Date of Birth
Child's First Name
Sex
MALE
FEMALE
Example: MM/DD/YYYY
MALE
FEMALE
Example: MM/DD/YYYY
MALE
FEMALE
Example: MM/DD/YYYY
MALE
FEMALE
Example: MM/DD/YYYY
MALE
FEMALE
-Which plan do you want to sign up for?
Health Plan:
Family Plan
$89.00
month to month
One-Time
$40 processing fee
($795 per year)
($3995 per 5 years)*
($6995 per 10 years)*
Senior Plan
($595 per year)
($2995 per 5 years)*
($4995 per 10 years)*
*application fee waived*
*A one time $20 Application Fee is applied...*