Participant Information

Member Information
SSN *  - -
First Name * 
Middle Initial  
Last Name * 
Gender * 
Birthdate *  / /
Billing Address
Address * 
  
City * 
State * 
Zip *  -
Additional Information
Home Phone *  - -
Work Phone   - -
Email * 
Beneficiary  
Agent ID * 
Agnt Member ID  
Group ID  
(Click here to set up a new Group)
Family Information
Number of Dependents *    
Product Selection

$10000 Accident Only Benefit

$5000 Accident Only Benefit

Co-Pay Drug - Family

Co-Pay Drug - Individual

NCSE Membership - Essential Dental

A $20 onetime fee plus $34.95 will be billed by provider and is not included here.
Not available in the following States:LA, ME, MA, NE,NY,NC, NV,OR,UT,WA

Executive I - Individual

Executive II - Individual

MedNet Dental Plan A - Family

MedNet Dental Plan A - Individual

MedNet Dental Plan A - Member+Children

MedNet Dental Plan A - Member+Spouse

MedNet Dental Plan B - Family

MedNet Dental Plan B - Individual

MedNet Dental Plan B - Member+Children

MedNet Dental Plan B - Member+Spouse

MedNet Dental Plan C - Family

MedNet Dental Plan C - Individual

MedNet Dental Plan C - Member+Children

An $8 billing convinence fee has been added to this product each month.
Not available in the following States: AR, KS, ME, RI

MedNet Dental Plan C - Member+Spouse

NBMARKETINGFEE

One time marketing fee

One-Time Application Fee(s)

  

Note - There may be a one-time enrollment fee of $25 or more for this application.

Enrollment Total

  

Monthly Total

  

Effective Date

 / /

Agreement

Please read carefully before agreeing: I hereby apply for co-pay drug product or Association, and by becoming a member, I understand that I am entitled to certain benefits and services made available through the Association / or co-pay product for its members and that dues or fees are required to be paid in order to maintain my membership in the Association / or co-pay product. I also understand that dependent children are covered to age 24 if enrolled full-time in an accredited school. By selecting the box below or signing this application for membership, I fully understand that the plans are not health insurance nor is this a replacement of health insurance.


(This box must be checked for the form to be processed)

I have read carefully the above statement, and agree to the terms and conditions stated within it.

Payment Method