JOIN
               Join

I would like to join this plan. I understand that this plan is not insurance. It is a reduced-fee-for-service program, and I am responsible for payment of services rendered by providers at the time of service.



 

 All fields are mandatory:

E-Mail:  

 

Mr Ms Mrs Miss

First and Last Name:  

Street Address:  

City:  

State:  

Zip Code:  

Telephone:  

 

Type of Plan:  

 Household 

$8.95/month

 Household 

$89.95/year

Payment Type:  

 Visa

 VISA

 Master Card

 Master Card

 American Express

 American Express

 Discover

 Discover

Credit Card Number:  

Expiration Date:  

 

For monthly payment, please charge my credit card each and every month in accordance with my selection above for the amount indicated for as long as I am a plan member. The first monthly charge will include the non-refundable one-time $10.00 application fee.

For yearly payment, please charge my credit card each and every year in accordance with my selection above for the amount indicated for as long as I am a plan member. The first yearly charge will include the non-refundable one-time $10.00 application fee.

I permit National Benefit Builders, Inc. (NBBI) to charge my credit card for these amounts. I understand that this plan is not insurance, and that payment for services rendered by providers is due at the time of service.

         

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