Membership Plan Application

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Effective Date
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Membership Type
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Form# 18109-W Required fields are indicated
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Agent Information
rep icon Name Tory Quick
phone icon Primary (920) 354-6306
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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.
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Contact an Agent
Please contact us for membership registering assistance.
(855) SURE-MED


Accident Medical Expense and Accidental Death & Dismemberment Insurance, Critical Illness Insurance, and Accident and Sickness Hospital Indemnity Plan 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, 9907-88-89, and 9908-23-02). Exclusions & Limitations Apply. Chubb, 202 Hall’s Mill Road, PO Box 1600, Whitehouse Station, NJ 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 KS, MD, ME, NH, OK, SD, UT and WA
Critical Illness insurance is not available to residents of CA, FL, KS, MD, ME, MT, NH, NY, SD, UT and WA
Hospital Insurance is not available to residents of CO, KS, LA, MA, MD, MN, NH, NJ, NY, SD, TX, UT, VT and WV

Pharmacy discounts range from 10% to 85% on most medications.

Complimentary Discount Benefit Disclosures:

The Discount Benefits listed above are NOT insurance nor is it intended to replace insurance. The plan 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 discount plan is provided at no cost as part of the association membership. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. 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

Dental Benefit is not available to VT residents.

The discount program provides access to the Aetna Dental Access® network, which is administered by Aetna Life Insurance Company (ALIC). ALIC does not offer or administer the discount program, and is not an affiliate, agent or principal of the discount program. Dental providers are independent contractors and not employees or agents of ALIC. ALIC does not provide dental care or treatment and is not responsible for outcomes.


© 2017 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.  Click here to view a Teladoc Access Map.


Lab benefit not available in MD, NJ, NY and RI.


Only spouse, domestic partner and/or legal dependent children of the primary member may be listed and receive benefits on a family membership.