Membership Application

1. Choose your Membership

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)

Ultimate Plus

Individual ($44.95 monthly/$499.00 annual)

Couple ($53.95 monthly/$598.00 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 *

Last Name *

Address *

City *

State *

Zip *

Phone *

Cell Phone

Email *

Gender * MaleFemale

Date of Birth (MM/DD/YYYY) *

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

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 *

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v11.5