ProMedical Application

APPLICANT INFORMATION

*First Name

Middle Name

*Last Name

Address

*Street Address

Address line 2

*Country

*City

*State

*Postal / Zip Code

*Primary Phone Number

Alternative Number

*Email

Fax Number

Effective Date

Group Name (If Applicable)

APPLICANTS INFORMATION AND PRIMARY CARE PHYSICIANS (PCP) SELECTION

Primary

*First Name

Middle Initial

*Last Name

*Gender

Date of Birth

*Primary Care Physician (PCP #)

*Plan Type

Include Application Fee ($35)

Agent Name

Agent Number

* Down Payment is calculated based on your first and second month of coverage depending on the plan rate you (and your dependents) fall into and it may or may not include your application fee depending on your choice.

The term of this agreement is on a month-to-month basis. Member may cancel at any time with a thirty (30) day advance written notice. To cancel this membership, mail or deliver a signed written notice with the reason to:

ProMedical Plan PHC, Inc.
400 Sawgrass Corporate Parkway Suite #200
Sunrise, FL 33325

If you decide to terminate your membership please email us at customerservice@promedicalplan.com

I have read and acknowledge terms above.