Creative Benefit Design :: Discount Benefits and More

HOME


	PREMIUM PLAN
	Dental
	Pharmacy
	NurseLine ™
	Lab Testing
	MRI & CT Scans
	Chiropractic
	Vision
	Hearing Aids
	Alternative Medicine
	Diabetic Supplies
	Durable Medical Equipment
	Ticket Monster

	PREMIUM PLUS PLAN
	All 11 Premium Benefits,
	Plus Physician Visit/Hospital Referral

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.

Mail your application to:

Creative Benefit Design
P.O. Box 3025
Terre Haute, IN 47803

Online Application:

Please fill out form completely. Fields marked with * are Required

Name of Organization:

Date of Birth:
Please use (xx-xx-xxxx) format.

Sex

Number of Dependents

Full Name:

Address:

City

County

State

Zip Code:

Daytime Contact Telephone:
Please include area code.
Please use (xxx-xxx-xxxx) format.

Daytime Phone

Email:

Plan and Payment Information:

Type of Plan and Billing - Select 1 Plan Only.

1 plan covers your enitre houshold.

---- Premium Plan ----
Product	Order
Billed Monthly $15.00 + One Time Admin Fee $5.00
Billed Annually $180.00 + One Time Admin Fee $5.00
*---- Premium Plus Plan ----*
Product	Order
Billed Monthly $19.00 + One Time Admin Fee $5.00
Billed Annually $228.00 + One Time Admin Fee $5.00

ADDITIONAL TERMS AND CONDITIONS: I understand my credit card will be billed monthly or yearly, depending on selected plan, and that this agreement will remain in effect until Creative Benefit Design has received a written notice from me that it should be cancelled. To ensure prompt cancellation of my Creative Benefit Design program, this notice must be submitted at least 15 days but not less than 3 days, prior to my next scheduled payment date.

Signature

Sign Here
Signature Required

By submitting this form, I agree to have Creative Benefit Design charge to my credit card the amount entered above and to the Terms and Conditions listed above.

We gladly accept
Accepted Cards

Fees:

Premium Plan
20.00 - Billed Monthly $15.00 + One Time Admin Fee $5.00
185.00 - Billed Annually $180.00 + One Time Admin Fee $5.00

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 Plan
24.00 - Billed Monthly $19.00 + One Time Admin Fee $5.00
233.00 - Billed Annually $228.00 + One Time Admin Fee $5.00

Premium Plus Includes
All 11 Premium Plan Benefits, Plus
Physician Visit/Hospital Referral

*Not Available in Kansas, Utah, Vermont, Washington* 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.

Form number: 63037A-W

	Privacy Statement