Your Personal
Health & Fitness Plan
Quote Acceptance Notice

Tell Me How

After you’ve received a Personal or Family health and fitness plan proposal and had your questions answered, how do you accept the components that you want and put your plan in place?

Go to the form below. Follow the instructions to complete it. Then, click on the “Submit” button to tell us what you want and to get the process underway.

Our total fitness program can help you develop a preventive health mindset, a positive fitness culture, a longevity plan that promotes a longer and higher quality of life, and an achievement mentality. Our Patient Care Services will help you better manage your individual or family healthcare affairs in less time and at lower cost.

You can enroll for individual or family membership in the Medical Self Care Prevention Plan, in the Medical Self Care Management Plan, in the Personal Fitness Program and in the Patient Care Assistance and Advocacy Services Plan.

Upon your acceptance, we will guide you to assemble any information and documents necessary for processing and enrollment. If all documents are available, the enrollment process typically requires only one to a few days. The ultimate deadline is usually the termination or renewal date for any existing insurance that is being replaced.

If you have questions or need additional information, go to our Contact Us Page.

WARNING: NEVER CANCEL YOUR CURRENT INSURANCE UNTIL REPLACEMENT COVERAGE IS APPROVED AND IN PLACE.

Start here . . . .

Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country*
Home Phone*
Quotation Date:*
Date Plan To Begin:*
FITNESS CULTURE PLAN SERVICES: I accept or reject the Fitness Culture Plan Services components as indicated below. Please charge my credit card account or my bank debit account as indicated:*
Yes - I Agree;
No.
Medical Self Care Prevention and Affairs Management Plan:*
Yes - I Accept;
No.
Total Personal Fitness Plan:*
Yes - I Accept;
No.
Patient Care Advocacy Services Plan:*
Yes - I Accept;
No.
Patient Care For Elders Services Plan:*
Yes - I Agree;
No.
BILLING AND PAYMENT: Payment of any initial processing fee and premium can be made by either Check Account Direct Deduction or by VISA or MasterCharge Credit Card in accordance with the appropriate authorization as may be selected and indicated below. It is recommended that you initially use a credit card account because it has more acceptable processing procedures and carries less risk to start through the free-look period. Once you have been approved by The Insurance Company and have accepted the policy and terms offered by The Insurance Company, you can change to a Direct Deduction option if that is your preference. Please select your preferred method of premium payment and complete the information below for your preference:*
Yes - I Agree;
No.
PREFERRED CREDIT CARD:
VISA;
MasterCharge.
Name on Credit Card: Credit Card Number (16 Digits): Credit Card Expiration Date: CREDIT CARD APPROVAL: I (we) authorize The Insurance Company and/or the appropriate service providers to charge my account for premium or services charges and for any start up or enrollment fees for the Medical Insurance policy and for any Fitness Culture Plan Services that I have approved and authorized herein. I understand and agree there will be no refund of charges after a ten-day free-look period after the effective date. Electronic Signature and Date Signed: *
AUTHORIZATION FOR CHECK-O-MATIC BILLING (Note: Do NOT approve check billing if you have selected credit card payment): Information to be provided will include: a desired withdrawal day of the month (1-28); Bank Name; City and State of bank location; Name(s) on Bank Account; Address on Bank Account (if different from residence); Bank Routing No. (9 Digits); and Bank Account Number. I hereby acknowledge and approve:*
Yes - I Approve;
No.
BANK ACCOUNT DEDUCTION AUTHORIZATION: I (we) hereby authorize The Insurance Company to initiate debit entries to the account and depository, hereinafter called Depository, as indicated, to debit the same from such account. After signature below, please provide all necessary information as indicated above. This authority is to remain in full force and effect until The Insurance Company and Depository have received written notification from me (or either of us) of its termination in such time and manner as to afford The Insurance Company and Depository a reasonable opportunity to act on it.” Electronic Signature of Payor and Date Signed:*
APPLICANT SIGNATURE: Any revocation of authority or approval by me must be sent by certified mail to the address as designated by The Insurance Company. Such revocation will not be valid if The Insurance Company has taken action in reliance on the authorization. Unless an earlier date is required by law, this authorization expires upon the earliest of the following events: denial of my application, declination of enrollment, or, if insured, when I am no longer an insured of The Insurance Company. I hereby acknowledge and agree. Electronic Signature of Proposed Insured and date signed:*

Please enter the word that you see below.

  

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