Membership Plan Application

Member Information line
Effective Date
Open the calendar popup.
Membership Type
X required
Address 1
Address 2
Zip Code
Form# 18109-W Required fields are indicated
box bottom
Agent Information
rep icon Name Tory Quick
phone icon Primary (920) 354-6306
phone icon Secondary -
Member Information
Keep your membership profile information up to date to insure usage of your benefits.
Verify Membership
Make sure the chosen membership type is correct, this will affect your benefits and pricing.
Effective Date
The earliest effective date you can choose is tomorrow. Your payment will be drafted on that day of each month.
rep icon
Contact an Agent
Please contact us for membership registering assistance.
(855) SURE-MED

Accident Medical Expense and Accidental Death & Dismemberment Insurance and Critical Illness Insurance are underwritten by Federal Insurance Company, a member insurer of the Chubb Group of Insurance Companies. The insurance described in this literature may not be available in all jurisdictions. This literature is descriptive only. Actual coverage is subject to the language of the policies as issued (Policy #s 9907-88-87, 9907-88-88, and 9907-88-89). Exclusions & Limitations Apply. Chubb, Box 1600, Whitehouse Station, N.J. 08889-1600.
The offer of insurance is null and void if United States trade or economic sanctions or other laws or regulations prohibit Federal Insurance Company from offering or providing insurance.
Accident Medical Expense and AD&D insurance is not available to residents of AR, MD, ME, NC, NH, OK, OR, SD, and WA
Critical Illness insurance is not available to residents of AR, CA, FL, MD, ME, MT, NC, NH, NY, OR, SD, and WA
Discount Benefits not available in FL, VT and WA.


This discount card program is NOT insurance, not intended to replace insurance, and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CRM 5.00. It contains a 30 day cancellation period, provides discounts only at the offices of contracted health care providers, and each member is obligated to pay the discounted medical charges in full at the point of service. For a complete list of disclosures, please click here. | Terms and Conditions | Discount Medical Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 671309, Dallas, TX 75367-1309.