Tell us about yourself

 Male  Female

Mailing Address

Billing Address

Spousal Information

 Yes  No
 Male  Female

Child Information

 Yes  No

Child #1

 Male  Female

Child #2

 Male  Female

Child #3

 Male  Female

Child #4

 Male  Female

Child #5

 Male  Female

Choose your coverage

Total: $0.00

Select your payment options

Accepted payment methods: credit card, bank transfer, direct bill.

 

Union Division

Electronic Payment Authorization

This is an authorization to allow the Third Party Administrator to deduct the fees associated with the products you have purchased. There will be a bank draft for the one time registration fee of $0 in addition to the dues of $0 on 6/25/2018. Monthly dues will be automatically drafted thereafter starting on 06/06/2016.

You have selected the following products:

  • None Selected

I, [Name Not Entered Yet], authorize the charge to my account for the amount indicated above at the above indicated frequency. I understand that I can cancel the product at any time and incur no further charges. I agree to notify the merchant in writing of any changes in my account information or termination of this authorization 15 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electonic transaction, these funds will be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account my comply with the provisions of US Law. I understand that cancellations must be made in writing and I will not dispute merchant recurring billing with my bank or credit card company, so long as the amount corresponds to the terms indicated in this contract.

 I Agree  I Disagree

By clicking the submit button, you will be enrolled in the selected products and your credit card or checking account will be billed for the amount selected. By clicking the button you also agree that all information provided is accurate and complete.

 I Agree  I Disagree