Register – Comedicard

*First Name

*Last Name

*Email

*Birth Date (ex: Day-Month-Year)

*Gender

Male

Female

Other

Please choose username and a password for account recovery purposes. Must be at least 6 characters long and include a combination of numbers and letters.

*Username

*Password

*Confirm Password

*Phone Number

*Address 1

*Zip

*City

*State

Authorized Agent Code (if applicable)

Full Name (indicate the name(s) of your dependent(s) below): Spouses or domestic partners and dependent children in the same household or under 26 years of age qualify for coverage.

Dependent 1

First Name

Last Name

Sex

Birth Date

Relationship

Dependent 2

First Name

Last Name

Sex

Birth Date

Relationship

Dependent 3

First Name

Last Name

Sex

Birth Date

Relationship

Dependent 4

First Name

Last Name

Sex

Birth Date

Relationship

Dependent 5

First Name

Last Name

Sex

Birth Date

Relationship

Dependent 6

First Name

Last Name

Sex

Birth Date

Relationship

Enrollment Terms

By clicking this box you acknowledge enrollment in the CoMediCard benefits membership and upon submission of this form, you authorize CoSurance Benefits to charge your credit card for the above amount for these agreed upon services. You agree that you understand that your information will be saved on file for future transactions on your account. The reoccurring billing will occur monthly. By processing this payment, you are agreeing to an automatic recurring payment and accept all reoccurring charges until you cancel your subscription. You may cancel your monthly subscription at any time, subject to the terms of our cancellation policy which can be found at CoMedicard.com/cancellationpolicy/. In the event your payment is declined or unable to be processed for any reason, you will be contacted by phone or email. In the event any payment is not made and you do not make the required payment by the end of your billing cycle, your service will be suspended or cancelled. Accounts will not be pro-rated. Processing is immediate. CoMedicard is not an insurance product and is not a substitute for health insurance or normal preventative medical care.

Accept our Terms&Conditions