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Member Application

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Primary

First Name

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DOB (MM/DD/YYYY)*

Zip Code*

Email*

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Application Summary

Name On Card*

Card Number*

Card Type*

Expiration Date*

CVV*

First Name*

Last Name*

Bank Name*

Select Account Type*

Routing Number*

Account Number*

Confirm Account Number*

Billing Information:

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Payment Summary	Member Rate	Group Rate	Full Rate
SubTotal(s)	$0.00	$0.00	$0.00
Healthy Steps -	$0.00	$0.00	$0.00
Service fee(s)	$0.00	$0.00	$0.00
Today's Total	$0.00	$0.00	$0.00

Monthly Payment	$0.00	$0.00	$0.00
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New Member Verification (Select One)

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Subject

<div>
<div style="text-align: center;"><font face="Arial"><span font-size:="" trebuchet=""><span style="color: rgb(51, 51, 51); font-size: 18px; font-weight: 600; caret-color: rgb(51, 51, 51);">One Step Closer!</span></span></font></div>

<div> </div>
<span style="color: rgb(51, 51, 51); font-family: Arial; font-size: 12px;">[[fname]], your enrollment application is ready for your review and approval.  Click the link below to gain access to your enrollment application.  </span></div>

<div>
<div style="font-size: 12px;"> 
<p class="mn" font-size:="" style="color: rgb(51, 51, 51); text-size-adjust: auto;" trebuchet=""><font face="Arial">Once you access the enrollment page by clicking the link above, you will follow the next basic steps:</font><br />
 </p>

<ul style="color: rgb(93, 93, 93); caret-color: rgb(93, 93, 93); text-size-adjust: auto;">
	<li style="color: rgb(51, 51, 51);"><font face="Arial">Verify primary member's date of birth to gain</font></li>
	<li style="color: rgb(51, 51, 51);"><font face="Arial">Review application accuracy for all policies you plan to purchase and billing method used (if applicable)</font></li>
	<li style="color: rgb(51, 51, 51);"><font face="Arial">Once satisfied, set a password for your member portal, agree to terms and conditions and sign the application</font></li>
	<li style="color: rgb(51, 51, 51);"><font face="Arial">Following approval, gain immediate access to your member's portal to view benefits and temporary ID cards that may be available</font></li>
</ul>
</div>
</div>
</div>

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Billing Address - Edit

Name*

Address*

Address 2 (suite, apt)

City*

State*

Zip/Postal Code*

Gross Income	Without Gap +	With Gap +
Federal Taxes State Taxes FICA Medicare	$0.00 $0.00 $0.00 $0.00	$0.00 $0.00 $0.00 $0.00
PreTax Deductions Gap+ Premium PostTax Deductions	$0.00	$0.00
Claim Payment	$0.00	$0.00
Take Home	$0.00	$0.00

Deduction Name	Calculation Method	Deduction Amount	X
Deduction Name	Deduction Name	Deduction Name	Deduction Name
Total			$0.00
+ Add Deduction			Done

Deduction Name	Calculation Method	Deduction Amount	X
Deduction Name	Deduction Name	Deduction Name	Deduction Name
Total			$0.00
+ Add Deduction			Done

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Dependent Information

Beneficiary Information

Application Summary

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New Member Verification (Select One)

Electronic Signature

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Billing Address - Edit

Welcome to Member application form

Member Application

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~product_name~

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$/~member_payment_type~

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$~product_total~/~member_payment_type~

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