Enrollment

Name*

First Name * Last Name *

Member ID #

Email Address*

Address*

‎ ‎ City State Zipcode

Phone

Provide required member details to see coverage options. Then choose desired coverage amount and whether or not you’d like to also cover your spouse.

Member Date of Birth*

Member Gender*

Male

Female

Coverage Amount

Member Signature*

You must agree to the use of an electronic signature.

Add Spouse

Spouse coverage will be equal to member's coverage amount.

Spouse Name*

Spouse First Name * Spouse Last Name *

Spouse Date of Birth*

Spouse Gender*

Male

Female

The rates quoted are based on age as of today. Your premium shown on your bill will reflect your age as of your effective date and may differ from above.

Payment Method

Bank Transfer

Bank Transfer (ACH)

Chasehps Payment

Credit card payment via Chasehps secure servers

Accidental Death Insurance Plan

Emergency & Accident

Property & Liability

Personal Insurance