High Plan – Individual and Spouse/Domestic Partner

Checkout Options

$29.46 USD / Monthly (recurring charge)

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First Name *

Last Name *

Email Address *

Username (lowercase alphanumeric) *

Password (type this twice please) *

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Additional Info

Current Address

Street Address *

Apt/Suite

City *

State *

Zip Code *

Sex *

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)

Date of Birth (1st Dependent)

Sex (1st Dependent)

Office Provider / Dentist Selection (1st 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.

Type Your Full Name *

Billing Method

Card Number (no dashes or spaces) *

Card Expiration Date (mm/yyyy) *

Card Verification Code * need help?

Card Start Date (mm/yyyy), or Issue Number *

Billing Address

Street Address *

City / Town *

State / Province *

Postal / Zip Code *

Country *

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