ALL - Infoarmor Enrollment

Entry Date

A Member Benefit of:

Services Provided By:

Select your plan option:

Complimentary InfoArmor Privacy Armor Plus identity protection through December 31, 2020.

No payment required for the Complimentary Offer and no obligation after expiration of complimentary service.

Select your coverage type:*

Individual ($9.95/month) Family ($17.95/month)

Dependent information is not required and will be collected once your account is setup with InfoArmor.

Monthly Cost $

Referral Code

THIS FIELD IS FOR MB AGENT USE ONLY

MB InfoArmor Web Enrollment & Electronic Signature Agreement

Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Member Benefits "sending party", whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.

Paper Copies

You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.

Withdrawal of Consent

You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.

Scope of Consent

You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below. You agree to receive communications from Member Benefits regarding coverage, program availability, and other important updates via email. Your privacy is extremely important to us; we do not sell personally identifiable information to outside parties, and we follow strict security standards. You have the ability to change email delivery preferences and/or opt out at any time. For a full summary of our privacy practices, please visit the Privacy Policy page.

Requesting paper copies, withdrawing consent, and updating contact information

You will have the ability to download and print any documents you complete through the electronic signature system. To request paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (support@memberbenefits.com) with the following subjects:

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

“Update Contact Information” Please provide your name, email, telephone number and postal address.

Email*

Confirm Email *

IMPORTANT: Your InfoArmor account will be associated with this email address. Please include valid email to agree to conduct business electronically. We do not SPAM. We do not sell or share your information with any outside entity not directly involved in providing this service to you.

Primary Enrollee Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Applying As:

Name*

First Name

Initial (optional)

Last Name

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Primary Enrollee Identification

You may add dependent information details once your account is setup with InfoArmor.

Gender*

Male Female

Date of Birth*

Member Name

Occupation

Employer Name (if employed)

Association Member ID#

If an Employee, list your Employer's Member ID#

Payment Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Payment Option 1 - Monthly Auto Pay
If you elect to pay by Monthly Bank Draft (ACH), you must complete the next Monthly Auto Pay (ACH) Authorization section. Upon approval of your enrollment form, we will automatically draft your account on a monthly basis.

Payment Option 2 - Annual Direct Bill (Initial payment via Credit/Debit Card)

If you select Annual Direct Bill, you are required to make your initial payment via Debit/Credit Card for the payment required to pay your subscription through the end of the group plan year (December 31st) plus a one-time $10.00 application fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st). Your card will not be charged thereafter and you will be invoiced on an annual basis for payment due January 1st each group plan year. At that time, you will be given the option to pay for your subscription via check, credit/debit card, or sign up for monthly auto pay.

I request the following payment basis (please check one):*

Monthly Auto Pay (ACH) Annual Direct Bill (Initial payment via Credit/Debit Card)

Initial Payment Due $

Annual Direct Bill Surcharge $

Credit/Debit Card Payment Authorization

Total Initial Payment $

Required payment to pay for coverage up through the end of the plan year (Dec 31st) + $10.00 Annual Direct Billing surcharge. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).

Credit Card*

One Time Credit/Debit Card Payment Authorization*

I hereby authorize Member Benefits to make a one-time debit to my credit/debit card listed above. By agreeing, I give permission to immediately debit my account upon completion of my online enrollment. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to my account. I authorize Member Benefits to charge the credit/debit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the insurance coverage described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

IMPORTANT:

Billing transactions from your account are performed by the plan administrator Member Benefits. Please make sure to recognize us on your bank statement as MEMBER BENEFITS

Monthly Auto Pay (ACH) Authorization

Type of Account*

Checking Savings

Account Owner’s Name*

Bank Name*

Bank’s Transit Routing Number*

Confirm *

Your Account Number*

Confirm *

IMPORTANT:

Monthly Auto Pay ACH Transactions from your bank account are performed by the plan administrator Member Benefits. Please make sure to recognize us on your bank statement as: MEMBERBENEFITS92

Monthly Auto Pay (ACH) Transfer Authorization:
I hereby authorize Member Benefits (MB) to initiate debit entries and to initiate, if necessary, credit entries as adjustments or any debit entries in error to my account at the Bank (or other Financial Institution) named below. I also authorize said Bank to debit and, if necessary, credit the amount of those entries to my account made payable to the order of MB. I understand and agree that: (1) My premium/contribution will be drafted on or after the 1st day of each month; (2) This authority is to remain in full force and effective until I provide written notification to MB that I wish to revoke it. I will provide MB thirty (30) days to act on my written notice; (3) MB and/or my Bank may discontinue or revoke this service for any reason; (4) The initiation of such debit or draft shall constitute due notice of premiums/contributions being due for a policy of insurance on my behalf and/or on behalf of my eligible dependents. Should my Bank dishonor any such debit or draft for any reason, it will be my responsibility to make payment arrangement with MB within the grace period to prevent lapse or possible termination due to nonpayment. MB will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid; and (5) I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I understand if the ACH debit is denied by my bank or financial institution, a $25 non-refundable service fee will be applied when allowed by law.

By my signature below I authorize Member Benefits in accordance with the Agreement to charge my bank account for the amount of my insurance premium payment until such time as I provide written notice of cancellation, or insurance is terminated.

Signature of Account Owner

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Enrollment/Membership Agreement

Complimentary Offer Agreement

I understand, unless further notified, my complimentary InfoArmor subscription service will expire on December 31, 2020. I understand Member Benefits may choose to extend this complimentary offer past December 31, 2020 and if so, will provide notice of such on or before December 31, 2020. I understand I will be provided the option to purchase an ongoing subscription however I am under no obligation to do so. I understand I may cancel my complimentary subscription at any time by submitting a cancellation request in writing to Member Benefits or by using the online Member Benefits cancellation form.

Member Benefits InfoArmor Membership Enrollment Agreement*

I hereby apply for the Member Benefits InfoArmor program, a service made available by Member Benefits and InfoArmor. To the best of my knowledge and belief, the information I’ve provided is complete and correct. I understand I am a participant in a group program and the plan provider, costs, service fees, eligibility requirements, and benefits may change. I have read and understand the conditions and plan limitations as described in the plan information through this website. I understand my service will end if my eligibility cannot be confirmed or if any required payment is not received or reversed by my bank. I understand that services will become effective on the next available enrollment date following approval of my enrollment and confirmation of my eligibility for this program. I understand once my enrollment has been approved, I will have access to create an account with InfoArmor in order to utilize this service. I understand Member Benefits and InfoArmor are independent contractors and not affiliated organizations. I understand that my service will be activated on the 1st of the month following my enrollment submission, after approval of my enrollment submission, and after sufficient administrative processing time of at least 5 business days. I understand all coverage changes and cancellation requests must be submitted, in writing or through the appropriate web form, directly to the plan administrator, Member Benefits. Change or cancellation requests submitted directly to InfoArmor will not be honored.

Signature*

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Affiliated Organization

Year End

Activate Date

Wait Days

Months