Enrollment: Complete form, Print, Sign & Date, and Fax to 1-281-847-1990
NBCA - CHECK PLAN TYPE:
Note: There is a one-time enrollment fee of $10 that will be charged on your
first month's bill, totalling $30 (individual) and $34.95 (family). After the first month, billing will return to $20 (individual) or $24.95 (family). All
membership applications are effective immediately upon receipt of payment.
CHURCH NAME:
PASTOR NAME:
APPLICANT NAME:
Gender
M
F
Address:
City:
State:
Zip:
Phone:
Email:
Birthday:
DEPENDENTS: The age limit for dependents is up to and including 24 years of age
1. Name
Relation:
Birthday:
2. Name
Relation:
Birthday:
3. Name
Relation:
Birthday:
Beneficiary INFORMATION:
Name
Relation:
Birthday:
PAYMENT METHOD: Check only ONE payment method
1. CREDIT CARD Card type:
Name as it appears on card:
Card number:
Expiration date:
Security code on back of card:
2. CHECKING ACCOUNT Name of bank:
Name as it appears on account:
Routing number:
Checking account number:
APPLICANT AGREEMENT:YES, I wish to enroll in the UCAA Gold Membership Plan and I agree to
the following: To the best of my knowledge and belief, the information on this application is
true and complete. It is offered to all insurance carriers providing coverage for the benefit of UCAA
members as the basis for any insurance issued.
Association Membership Enrollment Acknowledgement: I hereby acknowledge and understand
that I am accepting enrollment for the membership in the United Consumer Awareness Association
(UCAA). As a member of UCAA, I understand that:
(a) I will be able to access membership products, benefits and services; (b) That member
benefits are subject to change; (c) That membership will become effective upon receipt and
approval of the first month's membership payment amount and application; and (d) UCAA
membership is available to me if I have maintained a primary residence in the United States for
the past 12 month's or longer. (e) I understand and agree to the following: The Discount Medical
Plans included in the Association Membership are provided by Patriot Health Florida, Inc., a
discount medical plan organization. The plans are not health insurance and are not available in
all states. The plans provide discounts at certain health care providers for medical services and
does not make payments directly to the providers of medical services. The member is obligated
to pay for all health care services but will receive a discount from those health care providers who
have contracted with Patriot Health Florida, Inc., located at 160 Eileen Way, Syosset, New York
11791.
I hereby authorize NCBGI, Inc. to charge my credit card or bank account monthly
per the amounts checked above. I acknowledge that I have read and accept the terms and conditions
of my association membership. I also acknowledge that upon completion of this form and submission
of the initial monthly payment, I have fully accepted the terms and conditions included in my
membership kit. I hereby acknowledge and understand that this is NOT Major Medical Insurance and
is not a substitute for such. APPLICANT SIGNATURE:
Date:
