Member(s): $  + $ 20.00 (One time) Enrollment Fee = $

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Enrollment

Choose your plan.

Renew plans starting at $3.95/member

Members also receive preferred pricing on up to 5 Fitbit devices!

 

Member Details

First Name *
Middle Initial
Last Name *
Home Phone
Work Phone
Coverage *
Date of Birth *
Gender *
Email *

Address Details

Address Line 1 *
Address Line 2
City *
State *
Zip *

Payment information

Credit Card Number *
Name on Card*
Expiration Date (MM/YYYY)*
CVC (Security Code)*
Credit Card Billing Statement Address Line 1*
Address Line 2
City*
State*
Zip*

Account information & Effective Date

Application for membership where payment is successfully processed will be effective on the first day of the following month regardless of what date the application was received and payment was processed.

User ID *
Password *
Confirm Password *
Password must contain the following:
  •    Must be 8 characters or more
  •    Must contain an uppercase letter
  •    Must contain a lowercase letter
  •    Must contain a number
  •    Must contain special character, eg., #?!@$%^&*
  •    Password mismatch