Discount Medical Plan Application
Plan Selection
Select Product Type
Products Included: Dental, Vision, Telemedicine, Prescription.
Member Information
First Name
*
Please Enter First Name.
Last Name
*
Please Enter Last Name.
Suffix
Email
*
Please Enter Email.
Please Enter Correct Email.
Phone
*
Please Enter Phone Number.
Phone number should be 10 digits.
Address
*
Please Enter Address.
City
*
Please Enter City.
State
Zip Code
*
Please Enter ZIP Code.
ZIP Code should be 5 digits.
Date of Birth
Gender
Language
Notification Method
Best Time To Call
Effective Date
*
Please Select Effective Date.
Agent ID
*
Please Enter Agent Id.
Dependent Information
Dependent List
| Name | Gender | Type | DOB | Action |
|---|---|---|---|---|
| {{dependentlistrecord.dependentlist_name|trim}} | {{dependentlistrecord.dependentlist_gender}} | {{dependentlistrecord.dependentlist_type}} | {{dependentlistrecord.dependentlist_dob}} |
Dependent has been added successfully.
First Name
*
Please Enter First Name.
Last Name
*
Please Enter Last Name.
Suffix
Gender
Dependent Type
Date of Birth
Payment Information
Select Payment Method
|
There is a $1/month additional processing fee for ACH payments. |
First Name
*
Please Enter Billing First Name.
Last Name
*
Please Enter Billing Last Name.
Address
*
Please Enter Billing Address.
City
*
Please Enter Billing City.
State
Zip Code
*
Please Enter Billing ZIP Code.
ZIP Code should be 5 digits.
Accepted Payment Method Visa, MasterCard, American Express, Discover
Credit Card Number
*
(no spaces or hyphens please) Please Enter Card Number.
(no spaces or hyphens please) Please Enter Card Number.
CVC/CCV Code
Expiration Date
Bank Details
Routing Number
*
Please enter Routing Number.
Account Number
*
Please enter Account Number.
Bank Name
Name on Bank Account
*
Please enter, the name of the bank account.
Bank Account Type
Compass Xpress
|
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| Starting the {{selectedEffectiveDay}}'th of next month, you will see a monthly charge on your credit card from Compass Xpress for ${{selectedProductsInfo.monthlyFee|currency:'':2}}. | I, {{individualfirstname}} {{individuallastname}}, authorize Compass Xpress to charge my checking account immediately for the initial payment, and on the {{selectedEffectiveDay}}'th of each month, following the monthly fee detailed above. This payment authorization is valid and to remain in effect unless I, {{individualfirstname}} {{individuallastname}}, notify Compass Xpress of its cancellation according to the cancellation procedures in our Membership Agreement. Clicking the Purchase button below indicates my authorization. | ||||||||||||||||||||||||||
