MED-SENSE GUARANTEED ASSOCIATION MEMBERSHIP ENROLLMENT

Enroll in MSGA Sapphire. Click here to learn more.

SELECT YOUR MEMBERSHIP DETAIL

Individual: [$20/Month]
Family: [$30/Month]
Effective Date:

A. PLEASE COMPLETE THE FOLLOWING INFORMATION ABOUT YOURSELF, SIGN AND DATE WHERE REQUIRED

First Name: Sex: Male Female
Middle Initial: Date of Birth:
Last Name: Occupation:
Address: Email:
City: Day Phone:
State: Evening Phone:
Zip:

B. COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR ELIGIBLE FAMILY MEMBERS YOU WANT ENROLLED

Spouse’s Name:
Child’s Name:
Child’s Name:
Child’s Name:

E. AUTHORIZATION FOR AUTOMATIC BANK DRAFT OR CREDIT CARD PAYMENT

I am signing up for an automatic payment plan. I agree Health Insurance Innovations or its authorized agent may automatically debit my bank account or Credit Card for the amount due on or after the payment date. I can cancel this automatic payment at any time by calling or writing to Health Insurance Innovations or its authorized agent. I agree that Health Insurance Innovations or my financial institution can cancel automatic payment for my account for any reason, at any time, with or without prior notice to me. I understand that $25.00 will be charged for each transaction rejected for insufficient funds. I acknowledge that the origination of these debits to my account must comply with U.S. laws. I agree that this agreement remains in effect until canceled by Health Insurance Innovations or my financial institution or me. I have a copy of this agreement and I know I can also contact Health Insurance Innovations or its agent for a copy.

I Accept the Authorization for MSGA Registration
I do not Accept the Authorization for MSGA Registration


Please Select Your Payment Option: Bank Draft Credit Card

Complete to pay by automatic bank draft

(Note: You must attach a voided check from your checking or savings account to this enrollment)

Account Class: Checking Saving
Type of Account: Personal Business
Print Account Holder’s Name:
Bank Name:
Address:
Check Number:
Account Number:
Routing Number:

BILLING ADDRESS

Address:
City:
state:
Zip:

ENROLLMENT ACKNOWLEDGEMENT

I hereby enroll for membership in the Med-Sense Guaranteed Association (MSGA). As a member of MSGA, I understand that I will be able to access membership products, benefits, services and insurance plans. I acknowledge that member benefits are subject to change without notice.


ENTER YOUR FIRST AND LAST NAME EXACTLY AS ENTERED IN SECTION A ABOVE

Signature: Date:
Human Verification: