CyberX Group

Welcome to the Healthcare 212° enrollment form

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Select Plans *

Products	Coverage	Benefits	Rate

Premium(s): $

Association Fee(s): $

Total: $0

Association Fees	Price
No Premiums

Primary Insured

First Name*

Last Name*

Phone*

Email*

Date of Birth (mm/dd/yyyy) *

Age

Gender*

SSN / ITIN Number

Address Details

Address*

Apartment Number

City*

State*

Zip Code*

Dependents Detail

Dependent 1

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 2 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 3 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 4 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 5 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 6 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 7 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 8 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 9 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Dependent 10 Delete Dependent

Relation *

First Name *

Last Name *

Date of Birth (mm/dd/yyyy) *

Age

Gender *

SSN / ITIN Number

Payment Details

Payment Mode*

First Name On Card*

Last Name On Card*

Card Type*

Card Number *

Month*

Year*

Billing Information

Check this if the billing is same as personal address

Address*

City*

State*

Zip/Postal Code*

Date of Coverage

MEC Plan Enrollment Confirmation
Phone: 866-995-5944
Email: [email protected]

NEW ENROLLMENT

PARTICIPANT INFORMATION

First Name

Last Name

DOB

Gender

SSN

Residence Street Address:

COVERAGE LEVEL:

I certify that the above information is correct. I authorize my group to make deductions from my earnings necessary to provide my contribution for this coverage and understand that my group is performing this service for my benefit and not as an agent of any insurer. I understand that coverage is not in force until the effective date shown on the Summary Plan Description issued to me. If this form is accepted, this request for participation in my group plan will become part of the agreement between Providence Insurance Partners, LLC and my group.

Fraud Notice - The following general Fraud Notice is intended to comply with the laws of your state. If any part of such language is found in conflict, such language shall be construed as amended to the extent necessary in order to meet the minimum requirements of your state. Any person who, knowingly and with intent to defraud or deceive any insurance company, files an application containing any materially false, incomplete or misleading information may be guilty of committing a fraudulent insurance act which is a crime and may be subject to criminal prosecution.

Based on the Agreement signed by your group with Providence Insurance Partners, LLC, the monthly rate for MEC^TM is as follows:

I have read and understand the above rates, one of which applies to my enrollment based on my enrollment and any additional spouse and/or dependent enrollment as noted in the rates.

Signature:

Date: 12/27/2024

If you have any questions regarding this document, please contact Member Services (Monday - Friday 8am to 6pm) at 866-995-5944.

Premium Total	$0.00
Discount	$0.00
Total Monthly Premium	$0.00

Welcome to the Healthcare 212° enrollment form

Primary Insured

Address Details

Dependents Detail

Dependent 1

Dependent 2 Delete Dependent

Dependent 3 Delete Dependent

Dependent 4 Delete Dependent

Dependent 5 Delete Dependent

Dependent 6 Delete Dependent

Dependent 7 Delete Dependent

Dependent 8 Delete Dependent

Dependent 9 Delete Dependent

Dependent 10 Delete Dependent

Payment Details

Billing Information

Date of Coverage

NEW ENROLLMENT

PARTICIPANT INFORMATION

Order Summary

Welcome to Healthcare 212° enrollment form.

Welcome to the Healthcare 212° enrollment form

Primary Insured

Address Details

Dependents Detail

Dependent 1 Delete Dependent

Dependent 2 Delete Dependent

Dependent 3 Delete Dependent

Dependent 4 Delete Dependent

Dependent 5 Delete Dependent

Dependent 6 Delete Dependent

Dependent 7 Delete Dependent

Dependent 8 Delete Dependent

Dependent 9 Delete Dependent

Dependent 10 Delete Dependent

Payment Details

Billing Information

Date of Coverage

NEW ENROLLMENT

PARTICIPANT INFORMATION

Order Summary

Enrollment Application

Welcome to Healthcare 212° enrollment form.

Dependent 1