Health Allies - ExtraEtc.com!

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Company ID # EXTRAETC CORPORATION
Agent ID #	*

Primary Member Information
Title	*
First Name	*
Last Name	*
Suffix	*
Birthday	mm/dd/yy *
Gender	Female Male
Work Phone	*
Home Phone	*
Address	*
APT	*
City	*
State	*
Zip code	*

Dependent Information (if applicable)
First Name
Last Name
Suffix

First Name
Last Name
Suffix

First Name
Last Name
Suffix

First Name
Last Name
Suffix

Billing information
Credit Card Type
Card Holder Name
Card Number
Expiration Date	/ mm/yy *
CVV#	(last 3 numbers on back of card) *

By clicking on the box , the APPLICANT (who is designated above) agreed to be charged as per the method indicated above for the one-time, nonrefundable fee of $15.00 as well as the first month’s fee of $19.95. And to further authorize to continue to be charged $19.95 on a monthly basis, on or about the same time every month for the applicable monthly fees until such time that I revoke that authorization by contacting the Sales Organization directly. I acknowledge that I have read and agree to be bound by the terms and conditions as provided in the membership agreement.
I Agree

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Disclosure: The HealthAllies® Discount Program is administered by HealthAllies®, Inc., a discount medical plan organization located at 505 N. Brand Blvd., Suite 850, Glendale, CA, 91203, 1-888-910-8777. HealthAllies is not insurance. HealthAllies provides discounts at certain health care providers for medical services. HealthAllies does not make payments directly to the providers of medical services. The program member is obligated to pay for all health care services but will receive a discount from those health care providers who have contracted with the discount plan organization.
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You may cancel at any time. Members who cancel within 30 days of enrollment (within 30 days of receipt of membership materials for residents of CO, IN, MO, MT, ND, OH, OK, SC and SD) will receive a full refund. (The application fee, if applicable, is not refundable except in AR, CO and TN.) Note to Utah residents: This contract is not protected by the Utah Life and Health Guaranty Association. The program and its administrators have no liability for providing or guaranteeing service or the quality of service rendered.