Discount Medical Plan Application
Select the plan that best fits your needs.
If you wish to pay by check or money order or would rather submit an offline form, please use our printable pdf form
then mail or fax it to us as directed on the form. If you purchase a Package Plan any A La Carte items you'd like to add must be on a separate application.
First Step: Choose a plan
A La Carte
Build your own plan choosing your own combination of benefits.