Plan Selection

Household Members

Payment

Summary

Location

Zip

Plan {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism','ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Details' : 'Premiums'}}

Monthly Premium

{{(totalMonthlyPayment - ismMembershipPlanPayment)| currency:"$":2}}

{{(totalMembershipPlanPayment + ismMembershipPlanPayment)| currency:"$":2}}

Total {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism','ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? '' : 'Initial '}}Premium (including fees)

{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment + totalRecurringfees | currency:"$":2}}

MY PLAN SELECTIONS

{{supplementaryPlanConstants.getPlanCategoryByCode(category.code, selectedState)}} Selected

{{planOption.displayText}}
{{supplementaryPlanConstants.getAttributeValue('ism', 'membershipplanname')}}

{{planOption.planEffectiveDate}} Change

Insurance Company

Who is this plan for?

Birth Date

Gender

Relationship

self

Tobacco User?

Yes

+ Add Another Person

{{supplementaryPlanConstants.getPlanCategoryByCode(category.code, selectedState)}}

{{planOption.blockLevel ? planOption.blockLevel : supplementaryPlanConstants.getPlanCategoryByCode(category.code, selectedState)}}

{{planOption.displayText ? planOption.displayText : supplementaryPlan.displayText}}

Monthly Payment

{{bullet.bullet_text}}

Monthly Payment

+ {{planOption.setupFee|currency:"$":2}} one-time fee

Powered for individual listed on the plan

Monthly Payment

Enrollment fee

Monthly Payment

Membership Plan

{{(showISMDetails?'Less':'More')}} Details

Monthly Payment

Membership Plan

{{(showISMDetails?'Less':'More')}} Details

Monthly Payment

{{(showDetails?'Less':'More')}} Details

{{!!standaloneGlobal && standaloneGlobal.selectedIsmCount?'Member':'Insured'}}

{{question.questionText}} *

First Name *

Last Name *

Suffix

Street Address *

Apt or Unit

Gender *

City *

State *

Zipcode *

Email *

Phone *

Mobile *

I agree to receive future calls on my mobile number from the American Associations (or on the American Association’s behalf) regarding my membership or insurance, including renewal reminders, and other offers. These calls may use an automatic telephone dialing system, a prerecorded voice message, or text message. Providing my consent is not a condition to the purchase of any American Association’s goods or services.

Marital Status *

Save

SSN / TIN *

Birth State

Birth Place *

Language

Height *

Weight(pounds) *

Employment Information

Employer Name *

Occupation *

Job Title

Street Address

Apt or Unit

City

Zip Code

State

Employer Phone *

Work Hours

Hire Date

Annual Salary

How long have they worked there (in months)? *

Plan {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism','ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Details' : 'Premiums'}}

Monthly Premium

{{(totalMonthlyPayment - ismMembershipPlanPayment)| currency:"$":2}}

{{(totalMembershipPlanPayment + ismMembershipPlanPayment)| currency:"$":2}}

{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment + totalRecurringfees | currency:"$":2}}

MY PLAN SELECTIONS

{{supplementaryPlanConstants.getPlanCategoryByCode(category.code, selectedState)}} Selected

{{planOption.displayText}}
{{supplementaryPlanConstants.getAttributeValue('ism', 'membershipplanname')}}

{{planOption.planEffectiveDate}} Change

Owner Information

Different from Insured

Name *

SSN *

Relation *

Street Address *

City *

Zip Code *

State *

Email *

Spouse or Domestic Partner Information

First Name *

Last Name *

Suffix

Gender

DOB *

Relationship *

SSN

Birth State

Employment Information

Employer

Occupation *

Job Title

Work Hours

Hire Date

Annual Salary

How long have they worked there (in months)?

Dependent's Information

First Name *

Last Name *

Suffix

Gender

DOB *

Relationship *

SSN

Birth State

Employment Information

Employer

Occupation *

Job Title

Work Hours

Hire Date

Annual Salary

How long have they worked there (in months)?

{{question.questionText}} *

{{question.questionText}} * - in case of one applicant, the beneficiary must not be the applicant.

First Name *

Last Name *

Suffix

Relationship *

Birth Date *

Phone *

Address *

SSN

{{question.questionText}} *

Policy Questions - {{supplementaryPlan.carrierName}} - {{supplementaryPlan.productName}}

Policy Questions - {{supplementaryPlan.productName}}

Policy Questions - {{supplementaryPlan.productName.replace('AGENT',' AGENT')}}

{{question.questionText}} *

{{question.questionText}} * - in case of one applicant, the beneficiary must not be the applicant.

First Name *

Last Name *

Suffix

Relationship *

Birth Date *

Phone *

Address *

SSN

{{question.questionText}} *

{{question.questionText}} * - in case of one applicant, the beneficiary must not be the applicant.

First Name *

Last Name *

Suffix

Relationship *

Birth Date *

Phone *

Address *

SSN

{{question.questionText}} *

{{question.questionText}} * - in case of one applicant, the beneficiary must not be the applicant.

First Name *

Last Name *

Suffix

Relationship *

Birth Date *

Phone *

Address *

SSN

{{question.questionText}} *

Primary Doctor of each Applicant who has current and complete medical records (use Agent Notes section if more space is needed)

Spouse or Domestic Partner{{person.dependenttype}}'s (Dependent ) Doctor Address

Doctor's Name

Street Address

Apt or Unit

City

Zipcode

State

County

Phone

{{question.questionText}} *

{{question.questionText}} * - in case of one applicant, the beneficiary must not be the applicant.

First Name *

Last Name *

Suffix

Relationship *

Birth Date *

Phone *

Address *

SSN

{{question.questionText}} *

Continue >>

Defaults to primary applicant information - all fields are editable

Name as it appears on credit card or bank account

Billing Address Line1

Billing Address Line2

City

Zipcode

State

County

Credit Card

Bank Account

Card Type

Card Number

Expiration

Month

Year

CVV/CSC

Account Type

Bank Name

ABA Routing Number

Account Number

Payments via Credit Card will be charged an additional 3% processing fee each month. Your premium will be charged to your credit card monthly and will show up as “DIRECTCARE* DIRECTCARE” on your credit card statement.

{{cardDetails.identifier| uppercase}} ending with {{cardDetails.lastFourDigits}}

I hereby authorized Multiply Benefits LLC – plan administrator on behalf of the Premier Secure Life plans as offered through the Wellness Association of America (WAOA) to charge the designated credit card or debit card indicated in this authorization. I understand that this authorization will remain in effect until I cancel it in writing and agree to notify Premier Secure Life plan administrator in writing of any changes in my designated account information or termination request of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated by my enrollment form as authorized above. I certify that I am an authorized user of this credit / debit card or bank account from which funds will be withdrawn and that I will not dispute the scheduled payments with the designated Credit Card Company or bank provided the transactions correspond to the terms indicated in this authorization. I further agree that Multiply Benefits electronic treatment of each draft or debit, and ALL rights with respect to it, will be the same as if it were signed or initiated personally by me. I further agree that if any draft or debit is dishonored for any reason, Multiply Benefits will not be under any liability even though dishonor may result in the forfeiture of membership and any group insurance, benefits. I further agree that this authorization is to remain in effect until Multiply Benefits receives written notice from me of its revocation.

I hereby authorized Multiply Benefits LLC – plan administrator on behalf of the Protection PLUS Life plans as offered through the Wellness Association of America (WAOA) to charge the designated credit card or debit card indicated in this authorization. I understand that this authorization will remain in effect until I cancel it in writing and agree to notify Protection PLUS Life plan administrator in writing of any changes in my designated account information or termination request of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated by my enrollment form as authorized above. I certify that I am an authorized user of this credit / debit card or bank account from which funds will be withdrawn and that I will not dispute the scheduled payments with the designated Credit Card Company or bank provided the transactions correspond to the terms indicated in this authorization. I further agree that Multiply Benefits electronic treatment of each draft or debit, and ALL rights with respect to it, will be the same as if it were signed or initiated personally by me. I further agree that if any draft or debit is dishonored for any reason, Multiply Benefits will not be under any liability even though dishonor may result in the forfeiture of membership and any group insurance, benefits. I further agree that this authorization is to remain in effect until Multiply Benefits receives written notice from me of its revocation.

I hereby authorized Multiply Benefits LLC – plan administrator on behalf of the Secure Life PLUS plans as offered through the Wellness Association of America (WAOA) to charge the designated credit card or debit card indicated in this authorization. I understand that this authorization will remain in effect until I cancel it in writing and agree to notify Secure Life PLUS plan administrator in writing of any changes in my designated account information or termination request of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated by my enrollment form as authorized above. I certify that I am an authorized user of this credit / debit card or bank account from which funds will be withdrawn and that I will not dispute the scheduled payments with the designated Credit Card Company or bank provided the transactions correspond to the terms indicated in this authorization. I further agree that Multiply Benefits electronic treatment of each draft or debit, and ALL rights with respect to it, will be the same as if it were signed or initiated personally by me. I further agree that if any draft or debit is dishonored for any reason, Multiply Benefits will not be under any liability even though dishonor may result in the forfeiture of membership and any group insurance, benefits. I further agree that this authorization is to remain in effect until Multiply Benefits receives written notice from me of its revocation.

I agree to be charged a total of {{(undefined !== supplementaryPlan.premium ? supplementaryPlan.premium : planOption.premium)| currency :"$":2}} per month as payment for the supplemental plan(s) offered under {{supplementaryPlan.selectedOption.displayText.includes('AMERICAN ASSOCIATION OF PRIVATE EMPLOYEES')?'The ':''}}"{{ supplementaryPlan.selectedOption.displayText}}" coverage.

I agree to be charged a total of {{(undefined !== supplementaryPlan.premium ? supplementaryPlan.premium + totalMembershipPlanPayment: planOption.premium + totalMembershipPlanPayment)| currency :"$":2}} per month as payment for the supplemental plan(s) offered under {{supplementaryPlan.selectedOption.displayText.includes('AMERICAN ASSOCIATION OF PRIVATE EMPLOYEES')?'The ':''}}"{{ planOption.displayText}} and AAPE - Premium Plus Membership Plan" coverage.

I agree to be charged a one-time fee of {{(supplementaryPlan.selectedOption.setupFee| currency:"$":2)}}.

I agree to be charged a monthly service fee of {{(supplementaryPlan.selectedOption.setupFee| currency:"$":2)}}.

I agree to be charged a total of {{(undefined !== supplementaryPlan.premium ? supplementaryPlan.premium : planOption.premium)| currency :"$":2}} per month as payment for the supplemental plan(s) offered under The "{{supplementaryPlan.selectedOption.displayText}}" coverage.

{{disclaimer.title}}

Continue

Summary of Coverage

Insurance Coverage Purchased Products Purchased

Date Prepared: : {{getCurrentDate() | date : "MM/dd/yyyy"}}
Requested Effective Date: {{planOption.planEffectiveDate}}
Status: {{planOption.setAppStatus}}

Carrier : {{supplementaryPlan.carrierName}}

Plan Name : {{planOption.displayText}}

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}
AAPE - Premium Plus Membership Plan

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}

{{bullet.bullet_text}}

Telemedicine - 24/7 On Demand Healthcare, unlimited consults at no additional costs
Dental - Save 20-50% through one of the largest dental networks nationally
Pharmacy - Deep discounts at over 56,000 Pharmacy nationwide
Vision - Save 20-40% off the retail price of eyewear from over 65,000 providers nationwide

Covered:	DOB:	Relationship:
{{person.firstName + ' ' + person.lastName}}	{{person.dob}}	{{person.dependenttype}}

Monthly Premium: Membership Plan:

Association Fee:

{{(ismffaAgent) ? 'Monthly Service Fee: ' : 'Non Refundable Application Fee: '}} Alternate Setup Fee

{{(planOption.setupFee| currency:"$":2)}}*

Credit Card Fee:

Total{{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? ' Payment:' : ' Initial Premium:'}}

{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment | currency:"$":2}}

{{getISMInitialPremium(planOption.setupFee, planOption.premium) | currency:"$":2}}

{{getInitialPremium(supplementaryPlan) + planOption.recurringFee | currency:"$":2}}

{{getInitialPremium(supplementaryPlan) + planOption.creditCardFee | currency:"$":2}}

Total Monthly Thereafter:

{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment | currency:"$":2}}

{{getISMInitialPremium(planOption.setupFee, planOption.premium) | currency:"$":2}}

{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment | currency:"$":2}}

{{planOption.premium + planOption.creditCardFee| currency:"$":2}}

Total Initial Premium to be processed on the {{pslGlobal.firstPaymentDate}}:

Total Initial Premium to be processed on the {{getCurrentDate() | date : "MM/dd/yyyy"}}:

Total Monthly Thereafter to be processed on the {{getMonthlyBillingDueDate(planOption.planEffectiveDate, supplementaryPlan.carrier_id)}} day of each month:

Total{{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? ' Payment:' : ' Initial Premium:'}}

{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment + totalRecurringfees + fees.totalCreditCardFee| currency : "$":2}}

{{totalMonthlyPayment + totalSetupFee + totalRecurringfees + fees.totalCreditCardFee| currency : "$":2}}

Total Monthly {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Payment:' : 'Premium:'}}

{{totalMonthlyPayment + totalRecurringfees + fees.totalCreditCardFee| currency : "$":2}}

{{totalMonthlyPayment + totalMembershipPlanPayment + totalSetupFee| currency : "$":2}}

{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment| currency : "$":2}}

AUTHORIZATION FOR AUTOMATIC TRANSFER OR PROCESSING OF PAYMENTS:

I hereby authorize the transfer of funds held in the named institution for the purpose of making monthly payments for insurance products detailed above. I further authorize Multiply Benefits LLC to effectuate payment processing for insurance premiums due with funds held in the named institution. I authorize the named institution to effectuate transfer or processing of funds as if the transaction were signed personally by me. This authority is to remain in effect until I revoke same in writing, and I agree that each institution involved in any transfer shall be fully protected in honoring such transfers until such time. I further agree that if any transfer is dishonored due to any reason, the institutions involved shall be under no liability whatsoever. In addition, I authorize Multiply Benefits LLC to reverse any payment processed on my behalf if my transfer is dishonored for any reason. In the event that an erroneous electronic transaction is posted to my account, Multiply Benefits LLC may execute a reversal of that transaction.

Please enter your full name in the field below as your electronic signature, authorizing the purchase of the insurance products detailed above, and the processing of payments for the insurance premiums detailed above. *

AUTHORIZATION FOR AUTOMATIC TRANSFER OR PROCESSING OF PAYMENTS:

I hereby authorize the transfer of funds held in the named institution for the purpose of making monthly payments for products detailed above. I further authorize Multiply Benefits LLC to effectuate payment processing for benefit premium due with funds held in the named institution. I authorize the named institution to effectuate transfer or processing of funds as if the transaction were signed personally by me. This authority is to remain in effect until I revoke same in writing, and I agree that each institution involved in any transfer shall be fully protected in honoring such transfers until such time. I further agree that if any transfer is dishonored due to any reason, the institutions involved shall be under no liability whatsoever. In addition, I authorize Multiply Benefits LLC to reverse any payment processed on my behalf if my transfer is dishonored for any reason. In the event that an erroneous electronic transaction is posted to my account, Multiply Benefits LLC may execute a reversal of that transaction.

Please enter your full name in the field below as your electronic signature, authorizing the purchase of the products detailed above, and the processing of payments for the benefit premium detailed above. *

Mother's Maiden Name *

Premier Secure Life Initial Payment Date: Protection Plus Life Initial Payment Date: Secure Life PLUS Initial Payment Date:

{{pslGlobal.firstPaymentDate}}

ExpressRx Initial Payment Date:

{{expRxGlobal.firstPaymentDate}}

THC Initial Payment Date:

{{thcGlobal.firstPaymentDate}}

To the best of my knowledge and belief, the information contained on this membership enrollment application is true and complete. By my entering the Applicant/Owner Name and Mother's Maiden Name below, I am applying for membership in Wellness Association of America with Premier Secure Life Insurance Plan as issued and insured by Lifeshield National Insurance Company, Duncan OK. I have been advised of the participation requirements, understand and agree to the Member Terms and Conditions. I hereby acknowledge and understand that I must remain an active dues paying member of the Association to be / remain eligible for this group member benefits program. I further understand that membership benefits will not be in effect until my application for membership electronically processed and all necessary Association membership dues, fees and / or applicable benefits costs have been paid. If for any reason the membership plan is cancelled in the first 30 days of participation, all membership charges will be refunded except the non-refundable one-time $15.00 enrollment fee. Any person who, with intent to defraud or knowing that he / she is facilitating a fraud against the Association or an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Premier Secure Life Membership is NOT available in all states.

To the best of my knowledge and belief, the information contained on this membership enrollment application is true and complete. By my entering the Applicant/Owner Name and Mother's Maiden Name below, I am applying for membership in Wellness Association of America with Protection PLUS Term Life Insurance Plan as issued and insured by Lifeshield National Insurance Company, Duncan OK. I have been advised of the participation requirements, understand and agree to the Member Terms and Conditions. I hereby acknowledge and understand that I must remain an active dues paying member of the Association to be / remain eligible for this group member benefits program. I further understand that membership benefits will not be in effect until my application for membership electronically processed and all necessary Association membership dues, fees and / or applicable benefits costs have been paid. If for any reason the membership plan is cancelled in the first 30 days of participation, all membership charges will be refunded except the non-refundable one-time $25.00 enrollment fee. Any person who, with intent to defraud or knowing that he / she is facilitating a fraud against the Association or an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Protection PLUS Life Membership is NOT available in all states.

To the best of my knowledge and belief, the information contained on this membership enrollment application is true and complete. By my entering the Applicant/Owner Name and Mother's Maiden Name below, I am applying for membership in Wellness Association of America with Secure Life PLUS Life Insurance Plan as issued and insured by Lifeshield National Insurance Company, Duncan OK. I have been advised of the participation requirements, understand and agree to the Member Terms and Conditions. I hereby acknowledge and understand that I must remain an active dues paying member of the Association to be / remain eligible for this group member benefits program. I further understand that membership benefits will not be in effect until my application for membership electronically processed and all necessary Association membership dues, fees and / or applicable benefits costs have been paid. If for any reason the membership plan is cancelled in the first 30 days of participation, all membership charges will be refunded except the non-refundable one-time $25.00 enrollment fee. Any person who, with intent to defraud or knowing that he / she is facilitating a fraud against the Association or an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Secure Life PLUS Membership is NOT available in all states.

Voice Signature

Signature Verified

Applicant/Owner Name *

Mother's Maiden Name *

SUBMIT SUBMIT SUBMIT

Thank You

Thank you, your application has been submitted.

Thank You

Insurance Coverage Purchased Products Purchased

Wait, you have one more step to go to enroll in your plans!
Important: Click here to complete your application.

Date Prepared: {{getCurrentDate() | date : "MM/dd/yyyy"}}
Requested Effective Date: {{planOption.planEffectiveDate}}
Status: {{planOption.setAppStatus}}

Carrier : {{supplementaryPlan.carrierName}}

Plan Name : {{planOption.displayText}}

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}
AAPE - Premium Plus Membership Plan

Plan Name : {{planOption.displayText + (supplementaryPlan.planType ? (" - " + supplementaryPlan.planType) : "")}}

{{bullet.bullet_text}}

Covered:	DOB:	Relationship:
{{person.firstName + ' ' + person.lastName}}	{{person.dob}}	{{person.dependenttype}}

Monthly Premium:	Membership Plan:	{{planOption.premium\| currency:"$":2}}	{{planOption.premium - planOption.recurringFee\| currency:"$":2}}

Membership Plan Premium:	{{(ismffaAgent) ? 'Association Due: ' : 'Membership Plan: '}}	{{totalMembershipPlanPayment\| currency:"$":2}}

Association Fee:	{{planOption.recurringFee\| currency:"$":2}}

{{(ismffaAgent) ? 'Monthly Service Fee: ' : 'Non Refundable Application Fee: '}}	{{supplementaryPlan.selectedOption.setupFee\| currency:"$":2}}*

Credit Card Fee:	{{planOption.creditCardFee\| currency:"$":2}}

Total{{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? ' Payment:' : ' Initial Premium:'}}	{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment \| currency:"$":2}}	{{getISMInitialPremium(planOption.setupFee, planOption.premium) \| currency:"$":2}}	{{getInitialPremium(supplementaryPlan) + planOption.recurringFee \| currency:"$":2}}	{{getInitialPremium(supplementaryPlan) + planOption.creditCardFee \| currency:"$":2}}

Total Monthly Thereafter:	{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment \| currency:"$":2}}	{{getISMInitialPremium(planOption.setupFee, planOption.premium) \| currency:"$":2}}	{{getISMInitialPremium(planOption.setupFee, planOption.premium) + totalMembershipPlanPayment \| currency:"$":2}}	{{planOption.premium + planOption.recurringFee\| currency:"$":2}}	{{planOption.premium + planOption.creditCardFee\| currency:"$":2}}

Total Initial Premium to be processed on the {{getCurrentDate() \| date : "MM/dd/yyyy"}}:	Total Initial Premium to be processed on the {{pslGlobal.firstPaymentDate}}:	{{getInitialPremium(supplementaryPlan) \| currency:"$":2}}

Total Monthly Thereafter to be processed on the {{getMonthlyBillingDueDate(planOption.planEffectiveDate, supplementaryPlan.carrier_id)}} day of each month:	{{planOption.premium\| currency:"$":2}}

Total{{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? ' Payment: ' : ' Initial Premium: '}}	{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment + fees.totalCreditCardFee\| currency : "$":2}}	{{totalMonthlyPayment + totalSetupFee + totalRecurringfees + fees.totalCreditCardFee\| currency : "$":2}}

Total Monthly {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism', 'ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Payment: ' : 'Premium: '}}	{{totalMonthlyPayment + totalRecurringfees + fees.totalCreditCardFee\| currency : "$":2}}	{{totalMonthlyPayment + totalMembershipPlanPayment + totalSetupFee\| currency : "$":2}}	{{totalMonthlyPayment + totalSetupFee + totalMembershipPlanPayment\| currency : "$":2}}

To enroll Washington National Plans please click here.

To enroll Manhattan Life Plans please click here.

Location

Plan {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism','ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Details' : 'Premiums'}}

MY PLAN SELECTIONS

Insurance Company

Who is this plan for?

Birth Date

Gender

Relationship

Tobacco User?

{{planOption.blockLevel ? planOption.blockLevel : supplementaryPlanConstants.getPlanCategoryByCode(category.code, selectedState)}}

{{planOption.displayText ? planOption.displayText : supplementaryPlan.displayText}}

Monthly Payment

Monthly Payment

Monthly Payment

Monthly Payment

Monthly Payment

Monthly Payment

Monthly Payment

Membership Plan

Monthly Payment

Membership Plan

Monthly Payment

{{!!standaloneGlobal && standaloneGlobal.selectedIsmCount?'Member':'Insured'}}

Employment Information

Plan {{(distributorCarrierType != undefined && supplementaryPlanConstants.getAttributeValue(['ism','ismffa'], 'name').includes(distributorCarrierType.toUpperCase()))? 'Details' : 'Premiums'}}

MY PLAN SELECTIONS

Owner Information

Employment Information

Employment Information

Policy Questions - {{supplementaryPlan.carrierName}} - {{supplementaryPlan.productName}}

Policy Questions - {{supplementaryPlan.productName}}

Policy Questions - {{supplementaryPlan.productName.replace('AGENT',' AGENT')}}

Primary Doctor of each Applicant who has current and complete medical records (use Agent Notes section if more space is needed)

Spouse or Domestic Partner{{person.dependenttype}}'s (Dependent ) Doctor Address

Summary of Coverage

{{popupTitle}}

Initial Payment Date

{{popupTitle}}

Initial Payment Date

{{popupTitle}}

Initial Payment Date

Thank You

Thank You

Send a quote

* Enter Zipcode

* Select county

Selected county for this zipcode is

* Select Quote

* Select Primary Plan Type

^*Enter Zipcode

^*Select county

^*Select Quote

^*Select Primary Plan Type