MEMBERSHIP APPLICATION

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Household Membership (CA)

From: $60.00 for 1 year with a 5-day activation period

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 select your current health insurance status, then complete the information about your mailing address and household members.

Health insurance status?

Clear

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

Mailing Address *

Mailing State *

Mailing City *

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

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)

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

Referred by (optional)

PHI Employee ID (optional)

Base Code (optional)