Premier Plan – Enrollment – PhoneOps Insurance Agency, LLC

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Products
Benefit Plan
Group Plan
Contact Us

About Us

The argument in favor of using filler text goes something like this: If you use real content in the Consulting Process, anytime you reach a review

Contact Info

Chicago 12, Melborne City, USA
(111) 111-111-1111
Example@gmail.com
Week Days: 09.00 to 18.00 Sunday: Closed

PREMIER PLAN – ENROLLMENT

Most Popular

Premier Plan Includes:

Health News
Health Articles
Health Training
Accident Insurance ($2,500)
Critical Illness ($2,500)
Doctors by Phone
Counselors by Phone
Virtual Veterinarians
Dental Discounts
Vision Discounts
Prescription Discounts
Health Advocate Solutions
Labs
Diabetic Supplies
Diagnostic Imaging
Hearing Aids

Fees:

Enrollment Fee: $50
Single - $35 a Month
Couple - $45 a Month
Family - $55 a month
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Benefit Amount:
$2,500
$5,000
$7,500
$10,000
$15,000
$25,000

Most Popular

Optional Benefits:

Dental Insurance
Vision Insurance
Hospital Insurance
Life Insurance
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With Optional Benefits:
Enrollment fee: Remains $50
Monthly will be Additional
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Complete the enrollment form below to enroll in the plan that best fits your needs.

Full Name:

Contact Number:

Email Address:

Effective Date: (The earliest effective date you can choose is tomorrow. Your payment will be drafted on that day of each month.)

Address:

City:

State:

Date of Birth:

Social Security Number:

Gender:

Male

Female

Family Status:

Single

Couple

Family

Additional Members: For each additional member, add: Full name, DOB, Social Security Number, and relation to you. If this is a single plan, put N/A:

Benefit Amount: The Premium plan comes with Accident Insurance and Critical Illness at $2,500 benefit amount but you can increase this amount here:

$5,000

$7,500

$10,000

$15,000

$25,000

I will stay at $2,500 benefit amount

Select each additional benefits you would like to add:

Critical Illness-CI - (can't get CI by itself, must include DT, HI and/or LF)

Dental Insurance-DT

Hospital Insurance-HI

Life Insurance-LF

Vision Insurance-VS - (can't get VS without DT)

The next two screens will take you to the payment options. You will not be charged until we have spoken with you to review your plan and payment details, so no worries. Please make sure your phone number is correct and that you are available to answer our call. Do you understand?

Yes I understand

Payment Method:

Credit Card: I will complete this page

Bank Draft: (I will skip this page)

Name of Card:

Card Number:

If you are not using your own credit or debit card, what is your relationship to the cardholder?

Expiration Date:

CVV: (The Card Verification Value (CVV) is the 3-digit code on the back of the credit card, located to the right of the signature field. For American Express cards, this code is a 4-digit code located on the front of your card)

Full Billing Address:

Payment Method:

Bank Draft: I will complete this page

Credit Card: (Skip this page)

Name on Account:

If you are not using your own account, what is your relationship to the account holder?

Account Type:

Checking

Savings

Routing Number:

Account Number:

Please provide at least three days and times when you are available to review your plan and payment options.