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You may apply online with a credit card or download
the application print and mail it in with your check, money
order or credit card information.
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your application to: |
Creative Benefit Design
P.O. Box 3025
Terre Haute, IN 47803 |
 Please Select Your Plan:
Premium Plan Billed Annually $180.00
Plus One-Time Admin Fee of $5.00. |
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Premium Plan Billed Monthly $15.00
Plus One-Time Admin Fee of $5.00. |
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Premium Plan Plus Billed Annually $228.00
Plus One-Time Admin Fee of $5.00. |
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Premium Plan Plus Billed Monthly $19.00
Plus One-Time Admin Fee of $5.00. |
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Premium Plan Includes:
Dental
Pharmacy
NurseLine ™
Lab Testing/MRI & CT Scans
Chiropractic
Vision
Alternative Medicine
Hearing Aids
Diabetic Supplies
Durable Medical Equipment
Ticket Monster |
Premium Plus Includes
All 11 Premium Plan Benefits, Plus
Physician Visit/Hospital Referral |
We gladly accept
Lab Testing is not available to HI, MA, MD, ND, NJ, NY, RI, or SD residents.
Hospital benefit not available to MD, VT or WV residents.
Dental Benefit is not available to VT residents.
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Form number: 63037A-W |
