Membership Plan Application

Group Information line
Signup Type
Group Name
required
Email
required
Website
Phone
X required
Secondary
X
Address 1
required
Address 2
City
required
State
required
Zip Code
required
Effective Date
RadDatePicker
Open the calendar popup.
required
Payroll Period
required
Cost Share
required
Membership Type
required
Family Status
required
Benefit Amount
required
Form# 18109-W Required fields are indicated
box bottom
Agent Information
rep icon Name Ethan Selph
phone icon Primary (734) 471-2521
phone icon Secondary -
Group Information
Keep your group profile information up to date.
Verify Membership
Make sure the chosen cost share and payroll period are correct, this will affect your pricing.
Effective Date
The earliest effective date you can choose is tomorrow. Your payment will be drafted on that day of each month.
line
rep icon
Contact an Agent
Please contact us for membership registering assistance.
(855) SURE-MED




This program is NOT insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This program is provided at no cost as part of the association membership. This program 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. The range of discounts for medical or ancillary services provided under the plan will vary depending on the type of provider and medical or ancillary service received. For Terms and Conditions, click here. Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475, 800-800-7616. Customer Service: 855.SURE-MED.

Discount benefits not available to residents of VT and WA