Basic Plan – Individual and One or More Children Checkout Options $27.00 USD / Monthly (recurring charge) Gift, Coupon, or Redemption Code? Create Profile First Name * Last Name * Email Address * Username (lowercase alphanumeric) * Password (type this twice please) * password strength indicator Additional Info - Please scroll down and select your group or affiliationAction WiseCanonBentrust FinancialBick Insurance ConsultantsB SierraCabrera Benefits GroupArthur CohenEd Escobar, 360 Health AdvisorsMitch Freifeld, CIG BenefitsMcKinley FinancialMiaInsBrkEmployer Benefits ConsultingNone / Not Applicable Current Address Street Address * Apt/Suite City * State * Zip Code * Sex * FemaleMale Personal Details Date of Birth * Last 4 Digits of Social Security Number * Work Phone Home Phone Mobile Phone Office Provider / Dentist Selection List all dependents to be covered under this policy: Name (1st Dependent) Relationship (1st Dependent) SpouseDomestic PartnerChild Date of Birth (1st Dependent) Sex (1st Dependent) FemaleMale Office Provider / Dentist Selection (1st Dependent) Name (2nd Dependent) Relationship (2nd Dependent) SpouseDomestic PartnerChild Date of Birth (2nd Dependent) Sex (2nd Dependent) FemaleMale Office Provider / Dentist Selection (2nd Dependent) Name (3rd Dependent) Relationship (3rd Dependent) SpouseDomestic PartnerChild Date of Birth (3rd Dependent) Sex (3rd Dependent) FemaleMale Office Provider / Dentist Selection (3rd Dependent) Name (4th Dependent) Relationship (4th Dependent) SpouseDomestic PartnerChild Date of Birth (4th Dependent) Sex (4th Dependent) FemaleMale Office Provider / Dentist Selection (4th Dependent) Name (5th Dependent) Relationship (5th Dependent) SpouseDomestic PartnerChild Date of Birth (5th Dependent) Sex (5th Dependent) FemaleMale Office Provider / Dentist Selection (5th Dependent) Electronic Signature Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. * Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. 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