* = REQUIRED FIELDS. THESE DISCOUNTED RATES ARE AVAILABLE TO MEMBERS OF THE TEXAS NURSES ASSOCIATION WHO ENROLL BEFORE DECEMBER 31, 2019.

Choose which Global Medevac enrollment option is best for you: *
Individual Monthly Plan $30/moFamily Monthly Plan $38/moIndividual Annual Plan $350/yrFamily Annual Plan $450/yrIndividual 5-Year Plan $2250Family 5-Year Plan $3150Individual Lifetime Plan $2850Family Lifetime Plan $3850

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

Dependant's Information:

Note: Preexisting conditions are covered after 90-days

First Name

Middle Name

Last Name

Birthdate

Age

Second Dependant'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 *

Preferred Payment Method: *

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

Annual Check/Money Order PaymentAnnual Credit/Debit Card PaymentEFT/ACH Payment

Global Medevac Agent Information:

First Name

Last Name

Agent Number

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)

I have received, read and understand the Global Medevac Membership Agreement.