SELECT YOUR MEMBERSHIP DETAIL
A. PLEASE COMPLETE THE FOLLOWING INFORMATION ABOUT YOURSELF, SIGN AND DATE WHERE REQUIRED
B. COMPLETE THE FOLLOWING INFORMATION ABOUT YOUR ELIGIBLE FAMILY MEMBERS YOU WANT ENROLLED
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.
Complete to pay by automatic bank draft
(Note: You must attach a voided check from your checking or savings account to this enrollment)
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