Personal Information
First Name:
Last Name:


StreetAddress:
App#/Unit#:


City:
State:
Zip Code:

Home Phone:
Alt Phone:
Social Security Number:
Date of Birth:

AgentId
Email:
Fax:

Dependents
Name:
Date of Birth:

Social Security#:
Relationship to applicant:
Sex: M F

Name
Date of Birth:

Social Security#:
Relationship to applicant:
Sex: M F

Name
Date of Birth:

Social Security#:
Relationship to applicant:
Sex: M F

Name
Date of Birth:

Social Security#:
Relationship to applicant:
Sex: M F

Name
Date of Birth:

Social Security#:
Relationship to applicant:
Sex: M F

Plan Rates
Process Date:
Plan Type:
+ EnrollmentFee - $125 = $
(TOTAL)

Banking Information
Bank Name:

Routing Number:
Type of Account:
Checkings Savings

Account Number:
Check Number:

Terms Of Service : I agree that all this information is correct and not of fraudulent nature. By clicking this box, I agree that this policy is month to month, no contracts involved. Also, I agree to become a member of Premier health care with the initial enrollment fee of $125 which is non-refundable.

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