Entry Date










Services Provided By:


Select your plan option:
No payment required for the Complimentary Offer and no obligation after expiration of complimentary service.
Select your coverage type:*
Dependent information is not required and will be collected once your account is setup with InfoArmor.
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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.

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.

Name*
Mailing Address*

Primary Enrollee Identification

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

Gender*
Date of Birth*
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):*
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Credit/Debit Card Payment Authorization

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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).
One Time Credit/Debit Card Payment Authorization*

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*


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.

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Enrollment/Membership Agreement

Complimentary Offer Agreement
Member Benefits InfoArmor Membership Enrollment Agreement*
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Year End
Activate Date