EBA Enrollment Portal

Agent's Name *

First Name

Last Name

Effective Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Date of Birth

MM

DD

YYYY

Gender

Male

Female

Terms & Conditions *

Read the Terms & Conditions of Use

Yes, I have read and accept the Essential Benefit Administrators.

Payment Authorization *

I hereby authorize Essential Benefit Administrators to debit my Checking Account monthly. I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Essential Benefit Administrators in writing of any changes in my account information. In addition, I agree to provide notification at least 30 days prior to the next payment date if I wish to terminate this authorization. I understand that this is an electronic transaction and these funds will be withdrawn from my bank account.

If an ACH transaction is rejected for non-sufficient funds (NSF), I understand that Essential Benefit Administrators may, at its discretion, attempt to process the charge again within 30 days. A $35 fee will be assessed for any NSF‘s or payments rejected. I acknowledge the origination of ACH transactions to my account must comply with the provisions of US law. I agree not to dispute this recurring billing with my bank so long as the transactions correspond to the terms indicated.

Electronic Signature *

By writing my name below, I, the policy holder certify that I am above the age of 18, and have completed this form acuratly and the best of my knowledge.

First Name

Last Name

Today's Date *

MM

DD

YYYY

5% Credit Card Premium Fee *

I acknowledge that there is a 5% premium fee for credit cards.

Rx Flex Card

RX Flex Card copay discount card. This plan is not insurance. The formulary may not be accurate and change quarterly.

$25 - Individual

$35 - Individual + Spouse/Children