Additional Benefits Add-on benefits to strengthen your coverage LIFE | DISABILITY | HEALTH | DENTAL | 401(k) Retirement Order Number Total Monthly Total: $ BASIC PLAN for $1 * $1 / month Basic plan includes: - LIFE insurance for accidental death: $3,000 per adult, $2,000 per child in FL/ $1,000 per child all other states (subsequent years cost is $10/family per YEAR). Valid to age 70 max. - Prescription meds discount plan - save up to 70% on Rx drugs. - Access to Tel-a-Doc Doctor's virtual or telephonic visits, for non-emergency physician consultation, prescription refill, etc. You pay $49 or less per visit. DENTAL - discount plan, save up to 65% $12.95 / adult add $4 / child rider Immediate benefits, no waiting period! Pre-existing dental issues accepted! Dental discount plan saves you 50-65% on dental work, cleanings, x-rays, etc. HEALTH - accident reimbursement plan $17.70 / adult add $7.00 / child rider add $1.20 - Dr. visit reimbursement ($200 benefit each visit) Add more benefits - Need more LIFE insurance - from $6/mo. ($25,000 to $250,000) - will need to call for quote - Need more HEALTH insurance - from $70/mo. - comprehensive major medical, short-term - need to call for quote - Need DISABILITY insurance - from $25/mo. - need to call for quote - Need CANCER and CRITICAL ILLNESS benefits, from $15/mo., up to $50,000 benefit paid at first diagnosis - call for quote - Need 401(k) Retirement plan - call for plan setup Total Monthly total contribution: $ Start application for coverage Full Name Telephone Email State City Street address Zip Gender * Female Male DOB * SSN * Beneficiary info Beneficiary name Beneficiary DOB Beneficiary SSN# Family members covered Spouse name Spouse DOB Spouse SSN# Child1 name Child1 DOB Child1 SSN# Child2 name Child2 DOB Child2 SSN# Child3 name Child3 DOB Child3 SSN# Child4 name Child4 DOB Child4 SSN# Child5 name Child5 DOB Child5 SSN# Will this insurance replace other existing policy? (NOTE: this policy can not be issued to replace other existing life insurance policy) * No Payment info Account holder name FINANCIAL INSTITUTION Account # Routing #