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ON-LINE BANK CHECK ENROLLMENT APPLICATION                            

Your Name
Date of Birth (i.e. 10/20/65)
Gender  Male  Female
Social Security
Home Phone--area code first
Work Phone--area code first
Your Street Address
Your City
Your State
Your Zip
Applicant's Employer
Your Email Address
List Household Members:  
Household Member Name
Date of Birth (i.e. 10/20/65)
Household Member Name
Date of Birth (i.e. 10/20/65)
Household Member Name
Date of Birth (i.e. 10/20/65)
Household Member Name
Date of Birth (i.e. 10/20/65)
Household Member Name
Date of Birth (i.e. 10/20/65)
Household Member Name
Date of Birth (i.e. 10/20/65)
Bank Name
Routing #
Account #
Comments


Mail your check for payment and a voided check if paying monthly by bank draft - 30 day written cancellation notice required. 

Mail checks to:

Cignet Health Plan
P.O. Box 6500
Largo, MD  20792

By submitting your enclosed check, you are authorizing the ongoing Draft until Cignet Health Plan is notified of cancellation in writing.  Draft is taken on the 3rd of each month.

ESTIMATED ENROLLMENT COSTS

  Plan A Plan B Plan C Plan D
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 $45 $80 $120 $120
Drug Plan $12 $15 $18 $20
Catastrophic Care $41-138* $117-275* $152-358* $202-458*
Health Care Usage $100 $140 $275 $300
Maintenance Fee $10 $15 $20 $25
  TOTAL: $163-265 $287-450 $465-681 $547-813

*Rates apply to Maryland residents.  Call customer service for DC and Virginia rates.

NON-CATASTROPHIC ESTIMATED ENROLLMENT COSTS

  Plan A-NC Plan B-NC Plan C-NC Plan D-NC
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 $45 $80 $120 $120
Drug Plan with Dental Option $22 $25 $38 $40
Health Care Usage $100 $140 $275 $300
Maintenance Fee $10 $15 $20 $25
  TOTAL: $132 $180 $333 $365

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