Benefits Info Sheet

1. Personal Info **Please complete all fields**

Name

DOB

Male or Female

Social Security #:

Date of Hire:

Job Title:

Address:

City:

State:

Zip:

Phone:

Email:

Gross Annual Income:

Birth/State/Country:

3. How It Works

Pays CASH benefits directly to you, not the provider (doctor/hospital). Benefits can be used to pay co-pays, deductibles & other out of pocket medical expenses. Benefits are designed to pay everyday living expenses (i.e. rent/mortgage, car payment, groceries, utilities, etc.)

Plans are GUARANTEED renewable, meaning we will never cancel on you.

Policies are PORTABLE! Even if you change jobs, you can take it with you.

DEPENDENTS

First Name

Last Name

Date of Birth

Gender

Protect You Finances Plan For The Unexpected