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ON-LINE CREDIT CARD ENROLLMENT APPLICATION         
Note:  All Order Information Is Secure In Transit
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SELECT "PLAN" FOR QUICK ENROLLMENT

CATASROPHIC ESTIMATED ENROLLMENT COSTS
 

Number of Persons 1 2 Family 7+Family(high risk)
*Optional Vision $15 $30 $30 $30
*Optional Dental $50 $100 $100 $100
*Optional Dental & Vision $60 $120 $120 $120
Enrollment fee-one time $45 $80 $120 $120
Drug Plan $20 $25 $30 $40
Catastrophic Care $75-120* $110-160* $130-200* $140-210*
Health Care Usage $125 $180 $325 $350
Maintenance Fee $25 $30 $40 $45
  TOTAL: $245-290 $345-395 $525-595 $575-645

NON-CATASTROPHIC ESTIMATED ENROLLMENT COSTS

 

Number of Persons 1 2 Family 7+Family(high risk)
*Optional Vision $15 $30 $30 $30
*Optional Dental $50 $100 $100 $100
*Optional Dental & Vision $60 $120 $120 $120
Enrollment fee-one time $45 $80 $120 $120
Drug Plan $20 $25 $30 $40
Health Care Usage $125 $180 $325 $350
Maintenance Fee $25 $30 $40 $45
  TOTAL: $170 $235 $395 $435

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