* = Required fields

Choose which Global Medevac enrollment option is best for you: *
Member Preferred Hospital Services Region 2: Individual Monthly • $35/moMember Preferred Hospital Services Region 2: Family Monthly • $55/moMember Preferred Hospital Services Region 2: Individual Yearly • $410/yrMember Preferred Hospital Services Region 2: Family Yearly • $645/yrMember Preferred Hospital Services Region 2: Individual 5-Year • $1850Member Preferred Hospital Services Region 2: Family 5-Year • $2900Member Preferred Hospital Services Region 2: Individual 10-Year • $3275Member Preferred Hospital Services Region 2: Family 10-Year • $5150Member Preferred Hospital Services Region 1: Individual Monthly Preferred Hospital • $28/moMember Preferred Hospital Services Region 1: Family Monthly Preferred Hospital • $42/moMember Preferred Hospital Services Region 1: Individual Yearly Preferred Hospital • $325/yrMember Preferred Hospital Services Region 1: Family Yearly Preferred Hospital • $495/yrMember Preferred Hospital Services Region 1: Individual 5-Year Preferred Hospital • $1450Member Preferred Hospital Services Region 1: Family 5-Year Preferred Hospital • $2225Member Preferred Hospital Services Region 1: Individual 10-Year Preferred Hospital • $2600Member Preferred Hospital Services Region 1: Family 10-Year Preferred Hospital • $3950Member Services – Florida: Individual Monthly • $20/moMember Services – Florida: Family Monthly • $30/moMember Services – Florida: Individual Yearly • $230/yrMember Services – Florida: Family Yearly • $350/yrMember Services – Florida: Individual 5-Year • $1050Member Services – Florida: Family 5-Year • $1575Member Services – Florida: Individual 10-Year • $1850Member Services – Florida: Family 10-Year • $2800

Primary Member Information:

Note: Preexisting conditions are covered after 90-days

First Name *

Middle Name

Last Name *

Birthdate *

Age *

Your Email *

Mobile Phone Number *

Member's Spouse Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Spouse Email

Mobile Phone

Dependent's Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Second Dependent's Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Home Benefits Address:

Street Address *

City *

State *

Zip *

Mailing Address (IF DIFFERENT FROM HOME BENEFITS ADDRESS):

Street Address

City

State

Zip

Agent Information:

Agent Name

Agent Number

Preferred Payment Method: *

Note: a Global Medevac agent will reach out to you to process your payment

Annual Credit/Debit Card PaymentEFT/ACH Payment

REFERRAL INFORMATION:

(help someone else gain the ultimate peace of mind)

First Name

Last Name

Age

Email

Mobile Phone Number

Yes, I would like to receive Global Medevac's monthly life-saving news and information. (Please be sure to add Global Medevac to your email address book to avoid our information getting lost in your spam or junk email box)