Applicant Signature

Last Step!

Please read over the agreement terms and sign at the bottom to complete your purchase.

Health Choice+ Disclaimer:

Disclaimer: This web site provides a brief description of the plan. The Certificate will contain reduction, limitations, exclusions, and termination provisions. Full details of the coverage are contained in the Certificate. If there are any conflicts between this document and the Certificate, the Certificate shall govern. Health Choice+ is not available in all U.S. states or in countries outside the U.S. Coverage and benefits may vary by state. If you have any questions about the content at this website please contact us at 1-844-792-6985.

Health Choice+ Payment Authorizations and Acknowledgements

AUTHORIZATION FOR AUTOMATIC BANK DRAFT OR CREDIT CARD PAYMENT:

I am signing up for an automatic payment plan. I agree that MyBenefitsKeeper ("MBK") or its authorized agent may automatically debit my bank account or credit card for the amount due on or around the payment due date. The Payment shall appear on your statement as MyBenefitsKeeper. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify MBK or its authorized agent in writing of any changes in my account information or termination of this authorization, which must be received by MBK or its agent at least 7 days prior to the next billing date. If the above-noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above-noted periodic transaction dates. I agree that MBK or my financial institution can cancel automatic payment for my account for any reason, at any time, with or without prior notice to me. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that MBK or its agent may, at its discretion, attempt to process the charge again within 30 days, and I agree to an additional $25.00 charge for each attempt, which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of these debits to my account must comply with U.S. laws. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card or bank account. I agree not to dispute this recurring billing with my bank or card issuer so long as the transactions correspond to the terms indicated in this authorization form.

AUTHORIZATION FOR INSURANCE

IMPORTANT: I understand these benefits are provided under a group insurance policy underwritten by American Financial Security Life Insurance Company and are subject to exclusions, limitations and conditions of coverage which include, but are not limited to, an exclusion for pre-existing conditions. I certify that I have read or had read to me the completed enrollment form and the answers given are complete and true to the best of my knowledge and belief. By signing below I indicate my desire to enroll in a plan of limited medical benefits issued by American Financial Security Life Insurance Company.

Fraud Warnings

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines, confinement in prison and/or denial of insurance benefits. Fraud Warning for Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and maybe subject to restitution fines or confinement in prison or any combination thereof. Fraud Warning for Arkansas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison. Fraud Warning for Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purposes of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime. FRAUD WARNING FOR NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. FRAUD WARNING FOR OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claims for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NCE GapAfford Membership Participation Agreement

As a member of GapAfford Plus you are a participant in a Discount Medical Plan Organization provided by AccessOne Consumer Health, Inc. Below are the terms and conditions of your participation. This agreement is between you and AccessOne. The effective date of your enrollment is shown on the Member ID and shall continue from month to month until AccessOne is notified of your cancellation. DISCLOSURES:

  • The plan is not insurance;
  • The plan provides discounts at certain healthcare providers for medical services;
  • The plan does not make payments directly to the providers of medical services;
  • The plan member is obligated to pay for all healthcare services but will receive a discount from healthcare providers who have contracted with the discount plan organization;
  • The name and address of the licensed discount medical plan organization: AccessOne Consumer Health, Inc., 84 Villa Road, Greenville, SC 29615; 800-896-1962; www.accessonedmpo.com. You may find a list of participating providers at: www. NceGapAfford.com or you may call: 888-886- 1796. You will be able to apply plan discounts to all participating providers of each participating network.

You will receive discounts at participating chiropractors, medical equipment & supplies, rehabilitation services & diagnostic imaging centers ranging from 5% to 40%, prepaid Labs discounts of 5% to 70%, hearing services discounts of 5% to 20% and participating pharmacies provide discounts of 5% to 40%. The discounts for participating dentists range from 15-50% off standard billed charges, per visit, and average 20%. The vision services (including lenses and frames) are available at participating providers at discounts of 5% to 50% with an average of 25%. The Member Agreement (GAPMPA-P/0211), Member Guide (GAPGUIDE-P/0612x) and Member ID Card (GAPID-P/0211) represent the entire Agreement between you and GapAfford and AccessOne Consumer Health, Inc. You will be billed at the time services are provided by the participating provider who will apply the applicable discounts to that bill. In no instance can GapAfford or AccessOne make payments directly to a provider on your behalf. Your participation in the plan will continue from month to month upon payment of your monthly dues and shall cease upon (i) your failure to make the monthly payment; or (ii) notification in writing (USPS, email or facsimile) of your desire to cancel. You may cancel your membership in the discount medical plan organization within thirty (30) days after the effective date of your participation or receipt of your ID card, whichever is later, and receive a full refund less a minimal processing fee if applicable. After the first thirty (30) days, you may cancel participation at any time and if you have pre-paid any membership fees, the prepayment will be refunded on a pro-rata basis for the unused months. Notification must be received at least five (5) business days in advance of the next billing cycle for you not to be charged for that billing cycle. Participation in the program may be terminated if you fail to make a payment when due. This plan includes you and your dependent children at no charge. You are not required to list your dependents to participate in the plan. You may add children by calling AccessOne at 800-896-1962. If you have a complaint regarding the plan you may go to: www.accessonedmpo.com or call 800-896-1962. You may also write to AccessOne Consumer Health, Inc. 84 Villa Rd. Greenville, SC 29615. The complaint will be addressed, and you will receive a response within 15 days. THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This is not a Medicare prescription drug plan. This Agreement and its Benefit Descriptions represent the entire agreement between you, GapAfford and AccessOne Consumer Health, Inc. and supersedes all other prior representations, statements, or written agreements between you and GapAfford or AccessOne. Neither GapAfford nor AccessOne Consumer Health, Inc. has liability for providing or guaranteeing service or any liability for the quality of services rendered.

ScripPal Disclaimer:

ScripPal Disclaimer: DISCOUNT ONLY. NOT INSURANCE. Discounts are available exclusively through participating pharmacies and providers. The range of the discounts will vary depending on the type of provider and services rendered. This program does not make payments directly to providers. Members are required to pay for all health care services. You may cancel your registration at any time or file a complaint by contacting Customer Care at 1-866-788-6846. All prescription drugs are eligible for discount.

NOTICE OF CONSENT TO ELECTRONIC TRANSACTIONS, SIGNATURES AND DOCUMENTS:

I consent to use of electronic signatures of documents that would otherwise only be valid if they were in writing. I understand that MyBenefitsKeeper will rely on my signature as consent to receive the documents electronically unless I revoke this consent. I can update my information or revoke this consent at any time by calling MyBenefitsKeeper Customer Service Center at 844-792-3985 or support@mymbk.com. If you decide to withdraw your consent, the legal validity and enforceability of electronic transactions and signatures used prior to the withdrawal will not be affected. I may request specific documents at no cost in paper form at any time without revoking this consent. I agree to review the application produced by this voice signature carefully to ensure my understanding of all provisions of the coverage.

Authorization for Association

I hereby enroll for membership in the NCE Association at a cost of $12.50 per month. As a member of NCE I understand that I will be able to access membership products, benefits and services. I acknowledge that member benefits are subject to change without notice.

I consent to receive electronically all notices, communications and other documents of any kind from NCE and its benefit and service providers. I have the right to withdraw consent to such electronic transmittals; however, such withdrawal does not retroactively withdraw consent to actions occurring prior to such withdrawal.

These are not insurance benefits. These are association discount and lifestyle benefits and are not affiliated with any of the insurance companies or Accident Medical, Accidental Death & Dismemberment, Accident Disability Income, Critical Illness, Term Life Insurance, Hospital Indemnity, Limited Medical Benefits, Short-Term Medical, and, if selected, Dental Indemnity benefit and/or Insured Prescription Drug program.

Please enroll me today.

ADVANTHEALTH Disclaimer:

Disclaimer: This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check the Certificate carefully to make sure You are aware of any exclusions or limitations regarding coverage of Pre-Existing Conditions or health benefits (such as hospitalization, Emergency Services, maternity care, preventive care, Prescription Drugs, and mental health and Substance Use Disorder services). Your coverage also has lifetime and/or annual dollar limits on health benefits. If this coverage expires or You lose eligibility for this coverage, You might have to wait until an open enrollment period to get other health insurance coverage. This is a brief summary of AdvantHealth Short-Term Medical Insurance. Not available in all jurisdictions. Pre-existing conditions are not covered and benefits are subject to the policy limitations and exclusions. Refer to the policy, certificate and riders for complete details. AdvantHealth STM is underwritten by American Financial Security Life Insurance Company.

AdvantHealth Payment Authorizations and Acknowledgements

AUTHORIZATION FOR AUTOMATIC BANK DRAFT OR CREDIT CARD PAYMENT

I am signing up for an automatic payment plan. I agree that MyBenefitsKeeper ("MBK") or its authorized agent may automatically debit my bank account or credit card for the amount due on or around the payment due date. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify MBK or its authorized agent in writing of any changes in my account information or termination of this authorization, which must be received by MBK or its agent at least 7 days prior to the next billing date. If the above-noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above-noted periodic transaction dates. I agree that MBK or my financial institution can cancel automatic payment for my account for any reason, at any time, with or without prior notice to me. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF), I understand that MBK or its agent may, at its discretion, attempt to process the charge again within 30 days, and I agree to an additional $25.00 charge for each attempt, which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of these debits to my account must comply with U.S. laws. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card or bank account. I agree not to dispute this recurring billing with my bank or card issuer so long as the transactions correspond to the terms indicated in this authorization form.

Authorization for Insurance

I understand that benefits are provided under a group insurance policy underwritten by American Financial Security Life Insurance Company.

I understand that short term health insurance is not a substitute for comprehensive major medical insurance.

I understand that benefits are subject to exclusions, limitations and conditions of coverage which include, but are not limited to, an exclusion for pre-existing conditions. Coverage being applied for has a maximum benefit amount per coverage period and separate maximum benefit amounts for inpatient hospital, surgical, outpatient miscellaneous and certain other covered expenses.

I understand that any material misstatement or omission of information made on this form will be considered a misrepresentation and may be the basis for later rescission of my coverage and that of my dependents. In the event of rescission, the Insurer will refund premiums received for any coverage rescinded; however the Insurer will subtract total claim payments for the persons rescinded from this premium refund. If the insurer has paid claims in excess of the amount of premium received, the Insurer has the right to obtain a refund from me.

I declare that all statements contained in this Application are true and correct and that no information has been withheld or omitted concerning the past or present state of health about me or my named dependents. I understand that the above answers shall be the basis for the Insurer to issue coverage under the Group Policy.

By signing below I indicate my desire to enroll under a Short Term Medical Group Insurance Policy issued by American Financial Security Life Insurance Company.

I authorize the administrator to collect any and all premiums due under the policy. I understand that if I have elected the Monthly Payment option, my credit card will be charged each month on the due date of the premium for the duration of the policy, depending on the plan I have selected. I understand that I may terminate the scheduled payments by notifying the administrator at least one business day prior to the next scheduled payment date.

Fraud Warning

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Authorization for Association

I hereby enroll for membership in the NCE Association at a cost of $19.99 per month. As a member of NCE I understand that I will be able to access membership products, benefits and services. I acknowledge that member benefits are subject to change without notice.

I consent to receive electronically all notices, communications and other documents of any kind from NCE and its benefit and service providers. I have the right to withdraw consent to such electronic transmittals; however, such withdrawal does not retroactively withdraw consent to actions occurring prior to such withdrawal.

These are not insurance benefits. These are association discount and lifestyle benefits and are not affiliated with any of the insurance companies or Accident Medical, Accidental Death & Dismemberment, Accident Disability Income, Critical Illness, Term Life Insurance, Hospital Indemnity, Limited Medical Benefits, Short-Term Medical, and, if selected, Dental Indemnity benefit and/or Insured Prescription Drug program.

Please enroll me today.

ScripPal Disclaimer:

ScripPal Disclaimer: DISCOUNT ONLY. NOT INSURANCE. Discounts are available exclusively through participating pharmacies and providers. The range of the discounts will vary depending on the type of provider and services rendered. This program does not make payments directly to providers. Members are required to pay for all health care services. You may cancel your registration at any time or file a complaint by contacting Customer Care at 1-866-788-6846. All prescription drugs are eligible for discount.

NOTICE OF CONSENT TO ELECTRONIC TRANSACTIONS, SIGNATURES AND DOCUMENTS:

I consent to use of electronic signatures of documents that would otherwise only be valid if they were in writing. I understand that MyBenefitsKeeper will rely on my signature as consent to receive the documents electronically unless I revoke this consent. I can update my information or revoke this consent at any time by calling MyBenefitsKeeper Customer Service Center at 844-792-3985 or support@mymbk.com. If you decide to withdraw your consent, the legal validity and enforceability of electronic transactions and signatures used prior to the withdrawal will not be affected. I may request specific documents at no cost in paper form at any time without revoking this consent. I agree to review the application produced by this voice signature carefully to ensure my understanding of all provisions of the coverage.

DentaChoice

*Disclosure: This program is NOT INSURANCE. It is not a substitute for insurance nor does it qualify under the Affordable Care Act (ACA) or any state mandated provision. You must pay for services at the time they are rendered and you will receive a discount from participating providers. This plan is not available in AK, MT, RI, UT, VT & WA.

AUTHORIZATION FOR AUTOMATIC BANK DRAFT OR CREDIT CARD PAYMENT

I am signing up for an automatic payment plan. I agree that MyBenefitsKeeper("MBK") or its authorized agent may automatically debit my bank account or credit card for the amount due on or around the payment due date. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify MBK or its authorized agent in writing of any changes in my account information or termination of this authorization, which must be received by MBK or its agent at least 7 days prior to the next billing date. If the above-noted periodic payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above-noted periodic transaction dates. I agree that MBK or my financial institution can cancel automatic payment for my account for any reason, at any time, with or without prior notice to me. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF), I understand that MBK or its agent may, at its discretion, attempt to process the charge again within 30 days, and I agree to an additional $25.00 charge for each attempt, which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of these debits to my account must comply with U.S. laws. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card or bank account. I agree not to dispute this recurring billing with my bank or card issuer so long as the transactions correspond to the terms indicated in this authorization form.

Terms and Conditions

Savings indicated herein are based on providers' usual and customary fees. Discounts outlined herein cannot be used with any other discount plan or promotion. Prices charged by vendors may be adjusted from time to time without notice to the cardholder. Occasionally, certain vision providers may offer products or services to the general public at prices lower than our prices. In such an event, the member will be charged the lower price. This is a discount program, not insurance, and may be discontinued or modified at any time. AccessOne Consumer Health, Inc. (administrator) or National Benefit Builders, Inc. (NBBI) are not licensed insurers, HMO's or underwriters of healthcare services. No portion of any providers' fee will be reimbursed or otherwise paid to a participating member by AccessOne Consumer Health, Inc. or National Benefit Builders, Inc. (NBBI)

Providers in the program are solely responsible for the professional advice and treatment rendered to members. AccessOne Consumer Health, Inc. and National Benefit Builders, Inc. (NBBI) disclaim any liability with respect to such matters. AccessOne Consumer Health, Inc. and NBBI reserve the right to replace any network and will notify members accordingly. Discounts on professional services are not available where prohibited by law. For complaints, contact AccessOne Consumer Health Inc at 84 Villa Road, Greenville, SC 29615 or at the website www.accessonedmpo.com.

The Dentachoice Dental and Vision Program provides access to the Aetna Dental Access network. This network is offered by Aetna Life Insurance Company (ALIC). Neither ALIC nor any of its affiliates offers or administers the Dentachoice Dental and Vision Program. Neither ALIC nor any of its affiliates is an affiliate, agent, representative or employee of National Benefit Builders, Inc. (NBBI). Dental providers are independent contractors and not employees or agents of ALIC or its affiliates. ALIC does not provide dental care or treatment and is not responsible for outcomes.

NCE Dentachoice Membership Participation Agreement

As a member of NCE Dentachoice Plus you are a participant in a Discount Medical Plan Organization provided by Access One Consumer Health Below are the terms and conditions of your participation. This agreement is between you and Access One Consumer Health.

The effective date of your enrollment is shown on the Member ID and shall continue from month to month until NBBI is notified of your cancellation. La. R.S. 22:1260.7.D(1)(d) - The mode of payment of any processing fees and periodic charges and procedure for changing the mode of payment. La. R.S. 22:1260(5)(C) - If the discount medical plan organization cancels a membership for any reason other than non-payment of charges by the member, the discount medical plan organization shall make a pro rata reimbursement of all periodic charges to the member. La. R.S. 22:1260(7)(D)(1)(k) - Procedures for filing complaints under the discount medical plan organization’s complaint system and information that, if the member remains dissatisfied after completing the organization’s complaint system, the plan member may contact his state insurance department.

The cost for participation in the Plan is: Monthly [$19.99 per month for a household]. The initial payment includes a $5.95 fee upon enrollment, in addition to the Monthly fee.

DISCLOSURES:

The plan is not insurance;

The plan provides discounts at certain healthcare providers for medical services;

The plan member is obligated to pay for all healthcare services but will receive a discount from healthcare providers who have contracted with the discount plan organization;

The name and address of the licensed discount medical plan organization: Access One Consumer Health, 84 Villa Road, Greenville, SC 29615; 800-896-1962; www.AccessOnedmpo.com.

You may find a list of participating providers at: www.ncedentachoice.com or you may call: 877-271-6559. You will be able to apply plan discounts to all participating providers of each participating network.

The discounts for participating dentists range from 15-50% per visit off standard billed charges. The vision services (including lenses and frames) are available at participating providers at discounts of 5% to 50%. Participating pharmacies provide discounts of 15% to 55%.

The Member Agreement (AO-DACMPA2013,) and Member ID Card (AO-DACID2013) represent the entire Agreement between you and Access One Consumer Health You will be billed at the time services are provided by the participating provider who will apply the applicable discounts to that bill. In no instance can Access One Consumer Health make payments directly to a provider on your behalf.

Your participation in the plan will continue from month to month upon payment of your monthly dues and shall cease upon (i) your failure to make the monthly payment; or (ii) notification in writing (USPS, email or facsimile) of your desire to cancel.

You may cancel your membership in the discount medical plan organization within thirty (30) days after the effective date of your participation or receipt of your ID card, whichever is later, and receive a full refund. After the first thirty (30) days, you may cancel participation at any time and if you have pre-paid any membership fees, the prepayment will be refunded on a pro-rata basis for the unused months. Notification must be received at least five (5) business days in advance of the next billing cycle for you not to be charged for that billing cycle.

Participation in the program may be terminated if you fail to make a payment when due. This plan includes you and your dependent children at no charge. You are not required to list your dependents to participate in the plan.

If you have a complaint regarding the plan you may go to:

www.accessonedmpo.com or call 800-896-1962. You may also write to Access One Consumer Health 84 Villa Rd. Greenville, SC 29615. The complaint will be addressed and you will receive a response within 15 days.

THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR 5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. This is not a Medicare prescription drug plan.

This Agreement and its Benefit Descriptions represent the entire agreement between you and Access One Consumer Health and supersedes all other prior representations, statements, or written agreements between you and Access One Consumer Health. Access One Consumer Health does not have liability for providing or guaranteeing service or any liability for the quality of services rendered. Maryland Residents: The membership fee and one-time registration fee (minus $5.00) will be refunded if cancelled within the first 30 days and upon return of the discount card.

Massachusetts Residents: The Plan is not insurance coverage and does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. The range of discounts for medical or ancillary services provided under the Plan will vary depending on the type of provider and medical or ancillary service received. Nebraska Residents: If you have cancelled at any time after the 30 day period, and you have pre-paid any membership fees, the prepayment will be refunded on a pro-rata basis for months you have not used.

Texas Residents: If you are paying for the discount medical Plan, Access One Consumer Health or the Plan will cease collecting membership fees in a reasonable amount of time, but no later than (30) days after receiving a valid cancellation notice. This Plan is: regulated by the Texas Department of Insurance, P.O. Box 12157 Austin Texas 78711: telephone 1-800-252-3439 or (512) 463-6515; website: www.tdi.state.texas.com

West Virginia Residents: If after receiving our response and you are not satisfied with the resolution you may write of call: West Virginia Insurance Commissioner.

Renewal Conditions: By joining the plan, you are authorizing Local Health Insurance Corp to bill your credit card or checking account. This charge shall remain in force until you notify Local Health Insurance Corp in writing of its cancellation. This plan will automatically renew (monthly) until cancelled.

This program is not available in Alaska, Montana, Rhode Island, Utah, Vermont and Washington. Note: Keep a copy of the Member Agreement for your records.

ScripPal Disclaimer:

ScripPal Disclaimer: DISCOUNT ONLY. NOT INSURANCE. Discounts are available exclusively through participating pharmacies and providers. The range of the discounts will vary depending on the type of provider and services rendered. This program does not make payments directly to providers. Members are required to pay for all health care services. You may cancel your registration at any time or file a complaint by contacting Customer Care at 1-866-788-6846. All prescription drugs are eligible for discount.

NOTICE OF CONSENT TO ELECTRONIC TRANSACTIONS, SIGNATURES AND DOCUMENTS:

I consent to use of electronic signatures of documents that would otherwise only be valid if they were in writing. I understand that MyBenefitsKeeper will rely on my signature as consent to receive the documents electronically unless I revoke this consent. I can update my information or revoke this consent at any time by calling MyBenefitsKeeper Customer Service Center at 844-792-3985 or support@mymbk.com. If you decide to withdraw your consent, the legal validity and enforceability of electronic transactions and signatures used prior to the withdrawal will not be affected. I may request specific documents at no cost in paper form at any time without revoking this consent. I agree to review the application produced by this voice signature carefully to ensure my understanding of all provisions of the coverage.

Applicant Signature:

Date:

You understand Short-Term medical insurance is intended for temporary gaps in health insurance. It is not compliant with the federal Affordable Care Act and does not cover expenses related to pre-existing conditions.

Applicant Signature:

Date: