MEMBERSHIP APPLICATION

Select Membership Plan
Enter Member Details
Enter Billing Details

Household Membership (CA)

From: $60.00 for 1 year

This membership is available for a one year membership coverage. At the end of your membership coverage period, your membership will auto-renew. If you need to change your payment information or disable auto-renew, you can change this at any time under “My Account.”

Please complete in this order:

select your current health insurance status
complete the information about your mailing address and household members
click Continue

Health insurance status?

Clear

Are you a renewing member? Enter your membership ID. (optional)

Mailing Address *

Mailing City *

Mailing State *

Mailing Zip Code *

Phone *

Email *

Resident 1: First Name & Middle Initial *

Resident 1: Last Name *

Resident 1: Date of Birth *

Resident 1: Have insurance? * Yes No

I attest that those listed on this application reside together in the same household on a full-time basis. *

Resident 2: First Name & Middle Initial *

Resident 2: Last Name *

Resident 2: Date of Birth *

Resident 2: Have insurance? * Yes No

Resident 3: First Name & Middle Initial (optional)

Resident 3: Last Name (optional)

Resident 3: Date of Birth (optional)

Resident 3: Have insurance? (optional) Yes No

Resident 4: First Name & Middle Initial (optional)

Resident 4: Last Name (optional)

Resident 4: Date of Birth (optional)

Resident 4: Have insurance? (optional) Yes No

Resident 5: First Name & Middle Initial (optional)

Resident 5: Last Name (optional)

Resident 5: Date of Birth (optional)

Resident 5: Have insurance? (optional) Yes No

Resident 6: First Name & Middle Initial (optional)

Resident 6: Last Name (optional)

Resident 6: Date of Birth (optional)

Resident 6: Have insurance? (optional) Yes No

Enter any additional residents. Include First Name, Middle Initial, Last Name, Date of Birth, Have Insurance (optional)

Referred by (optional)

PHI Employee ID (optional)

PHI Base Code (optional)

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