Membership Plan Application

Member Information line
Effective Date
RadDatePicker
Open the calendar popup.
required
State
required
Membership Type
required
Email
required
Phone
X required
Secondary
X
Address 1
required
Address 2
City
required
State
Zip Code
required
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 -
bottom
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.
line
rep icon
Contact an Agent
Please contact us for membership registering assistance.
(855) SURE-MED

Disclosures
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 MD, ME, NH, OK, SD and WA
Critical Illness insurance is not available to residents of CA, FL, MD, ME, MT, NH, NY, SD and WA

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