Membership Application
Have you already applied?
1. Choose your Membership
Basic
Individual
(9.95 monthly/$119.00 annual)
Couple
($13.95 monthly/$167.00 annual)
Defender
Individual
($14.95 monthly/$179.00 annual)
Couple
($19.95 monthly/$239.00 annual)
Ultimate
Individual
($34.95 monthly/$399.00 annual)
Couple
($41.95 monthly/$479.00 annual)
(*) Rates shown include all applicable premiums, taxes, and fees.
2. Choose your Payment Term
Annual
Monthly
*
3. Confirm Your Information
Applicant Information
First Name
*
MI
Last Name
*
Address
*
City
*
State
*
--Select One--
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DIST. OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW MEXICO
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WEST VIRGINIA
WISCONSIN
WYOMING
Zip
*
Phone
*
Cell Phone
Email
*
Gender
*
Male
Female
Date of Birth (MM/DD/YYYY)
*
Spouse Information
First Name
*
MI
Last Name
*
Gender
*
Male
Female
Date of Birth
*
Emergency Contact
In an emergency, we may need to contact family members or friends about your situation.
Please list someone we may contact:
Primary
Contact Name
Relationship
Home Phone
Cell Phone
Email Address
Add Secondary Emergency Contact
Secondary
Contact Name
Relationship
Home Phone
Cell Phone
Email Address
Promo Code
Recruiter Information
If you were referred by a Second Call Defense Recruiter, please provide Name and ID#
Recruiter Name
Recruiter ID #
THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE. THE SUBMITTAL OF THIS APPLICATION DOES NOT BIND THE COMPANY TO OFFER NOR APPLICANT TO ACCEPT INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE INSURANCE APPLIED FOR. ANY SUCH INSURANCE ISSUED BY THE COMPANY AND ACCEPTED BY THE APPLICANT MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE INSURANCE WAS OBTAINED THROUGH ANY FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF ANY FACTS MATERIAL TO THE ACCEPTANCE BY THE COMPANY OF THE RISK OR HAZARD ASSUMED.
Accept
*