Step 1 - Enter PCI card holders Information

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Sign-up now to take advantage of our savings for dental, optical, prescription, dining, and shopping, for only $14.95/month. (Please note this offering is for a limited time that you can extend to your employees and their families).

Billing Address

Billing address and phone number MUST match the information on your credit card statement.

            Access Code:       *Required
            If none then please enter how you found out us.

*First Name:

*Last Name:

*Address:

Address 2:

Dependents:

Your whole family is covered with this plan. Please enter the names of your legal dependents that you would like to have covered below:

*City:

*State:

*Zip Code:

Check Information

Please enter your Check Information (see sample check):

*Account Holder Name:

*Routing Number: (9 digits)

*Account Number:

*Check Number:

*Account Type:

Bank Information:

*Bank Name:

*Bank City:

*Bank State:

Bank Zip Code:

I only have a debit card.

Credit Card Information

Credit Card Type:	*Please Select
Cardholder Name:	*Required
Card Number:	*Required
Expiration:	Required Required

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Terms
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Please enter your last name which will serve as your signature: