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Enroll Now!

Please use our online enrollment form or print the attached PDF and mail or fax it to us.

National Benefit Consulting, Inc.
P.O. Box 5577
Plymouth, MI 48170 

Discount Health Application

Annual cost to enroll: $49.00

ABOUT YOU
Email
First Name
Middle Initial
Last Name
Street Address
City
State
ZIP code
Home telephone
Gender	male female
Date of birth
Other household members:
(1) Name:	Date of birth:
(2) Name:	Date of birth:
(3) Name:	Date of birth:
(4) Name:	Date of birth:
(5) Name:	Date of birth:
For additional names, please add names and birthdates here:

 

Make $49.00 check payable to: NBC, Inc.

Mail to: PO Box 5577 
Plymouth, MI  48170

Your cards and important informational materials will be sent within 10 business days.