A COMMON SENSE SOLUTION TO CONTROLLING THE HIGH COST OF PRESCRIPTION DRUGS

Prescription Drug Card

 

ALL FIELDS LISTED BELOW MUST BE COMPLETED

** proper email address required as confirmation of enrollment will be sent**

E-mail  
First Name  
Last Name  
Street Address  
Address (cont.)
City  
State/Province  
Zip/Postal Code  
Home Phone With Area Code  (example 555-555-1212)
Date of Birth   (example 09/09/1952)
Social Security Number    (example 999-99-9999)

If Applying for Spouse Coverage                   

First Name
Last Name
Date of Birth
Social Security Number

If Applying for Dependent Coverage        

First Name
Last Name
Date of Birth
Social Security Number

 

First Name
Last Name
Date of Birth
Social Security Number

 

First Name
Last Name
Date of Birth
Social Security Number

NOTE: Please remember you will not be enrolled in the prescription plan until we receive your check!

*TO AVOID DOUBLE ENROLLMENT, PLEASE DO NOT CLICK THE SUBMIT BUTTON MORE THAN ONCE!  Thank You

Agent Insurance Mall  (AIM)
Copyright © 2000 Agent Insurance Mall  (AIM).  All rights reserved.

Created on ... October 23, 2001