Cdl Class Grand Junction

Member Information

Name: Barry Thomas

Address: **** * ******** **, ***** Junction, CO 81504

Phone: 970-***-****

Email: ad5ygn@r.postjobfree.com

Date of Birth: 08-10-1976

Gender: M

Dependent Information

Name Relationship Date of Birth Gender SSN

Heidi Compagni Spouse 04-21-1974 F

Product Information

AMT- Rx+Dental

$97.93 per Month for Individual plus Spouse

$0.00 one-time Enrollment

Terms and Conditions for AMT- Rx+Dental

Today is 05/07/2024

Please confirm your Barry Thomas

Will you please confirm your address 3158 E Mandarin Ct, Grand Junction, CO 81504 Will you please confirm your date of birth August 10, 1976 Will you please confirm your email address is ad5ygn@r.postjobfree.com. Will you please confirm your phone number is 970-***-****. Mr. / Ms. Barry Thomas, you do understand that you are purchasing the Lifestyle Program which is a membership-based wellness program which provides certain ongoing wellness and lifestyle services and discounts. You do understand this package of benefits is not insurance or a discount medical plan, but a membership program that provides you with free access to certain program features that offers a range of discounts for your dental, prescription and other lifestyle needs. You do understand that you are responsible for paying the discounted rates directly to the provider at the time of service. This program is prohibited from paying providers directly for services rendered. You do understand that if there are any discrepancies between what the specialist told you about the plan and what the actual plan states, that the plan terms will apply. This is a separate program from your primary health insurance plan. This plan is not insurance. This plan is not a Qualified Health Plan under the Affordable Care Act. This plan does not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR 5.00. The plan provides discounts at certain healthcare providers for services. By providing signature below I agree that my cell phone number on file will receive calls and texts to that number from the company that may be automatically dialed or prerecorded. Msg & Data Rates May Apply. Text STOP to opt out. Today's charge is $97.93 you will be charged $97.93 on the 8th of every month, and you do authorize us to process these charges on the credit card ending in xxxx-xxxx-xxxx-5846 with expiration date of 03/2028. You confirm that you are the authorized holder of this credit card. You understand that no prior-notification will be provided unless the date or billing amount changes. If, after using the program at any time you are not satisfied with the program, you may cancel your membership, and your benefits will be terminated at the end of the billing cycle for which you were billed, and you will not be billed any further. You have the right to cancel this plan within 30 days after the effective date for a full refund of fees paid. Also if we cannot collect the payment on the payment date your membership benefits would be terminated. In addition to membership discounts for specific prescription and dental benefits, you will have access to Lifestyle Services and Discounts including cash back online with 4,000+ retailers, discounts on Disney theme parks, movie tickets, etc., discounts on national gym memberships, and tele-dentist, tele-veterinarian and mental wellness discounts. By signing below, you understand and agree that this program does not meet the minimum essential coverage requirements set forth by the Affordable Care Act. You will receive your membership kit electronically in 1 to 3 business days AFTER your effective date, which includes your online registration and detailed information regarding your benefits. As soon as your membership application is processed the FIRST STEP in obtaining your lifestyle and health-related assistance requires you to login to your Member Portal. In your member portal, you will be prompted to follow a few simple steps: sign your terms and conditions, fill out the necessary required info, and login to your member portal to access your benefits online. If you have any billing issues, have any questions or wish to discontinue this plan, you must call US directly at our customer service department's toll-free number, again, which is

855-***-****. Thank you for your time!

Payment Method

Type: Credit Card

Name: Heidi Compagni

Number: xxxxxxxxxxxx-5846

Expiration: March 2028

Electronic Signature

By electronically acknowledging this authorization, I acknowledge that I have read and agree to the terms and conditions set forth in this agreement.

Signed as Parent / Guardian

Name: Barry Thomas

Date: May 7, 2024 at 11:06:36 AM

IP Address: 174.218.170.253

System: Mozilla/5.0 (iPhone; CPU iPhone OS 17_4 like Mac OS X) AppleWebKit/605.1.15

(KHTML, like Gecko) CriOS/124.0.6367.111 Mobile/15E148 Safari/604.1

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