MEMBER INFO

When prompted, use the email address associated with your JustAnswer membership. Discount Plan Application

Primary Member

* First Name

* Last Name

* Gender

* Date of Birth (mm/dd/yyyy)

Dependents

Dependent information is not required for the purchase of discount benefit plans. All legal dependents can receive discounts using the card issued in the main member's name. If you would like to receive additional cards reflecting the name of your dependents, check the “Print Card” option for each dependent that should receive a personalized card. Each dependent card requested after the first may result in a one-time printing charge in addition to the price of your benefit purchase today. All recurring payments will be processed for the price of benefits only (when applicable).

Charge: $0.00

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

Dependent	* Date of Birth (mm/dd/yyyy)	Print Card
Dependent		Print Card
* First Name	* Last Name

* - required

Form #NB-teidsp

This program is not insurance nor is it intended to replace insurance. There is a 30-day cancellation period from the date of purchase for any reason.