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ENROLL
Online Enrollment Form
To be eligible, all persons listed on the enrollment form must be permanent residents of the listed address.
There is a one-time enrollment fee of $10 for the Plan.
Please complete the enrollment form TODAY so that we may process your request immediately. Plan benefits will begin on the 1st day of the month following receipt of your enrollment. If today is the 1st of the month, your benefits will start TODAY.
WBA uses a true Secure Enrollment system powered by Plug'N'Pay Technologies to assure the confidentiality of your personal information.
For Security Purposes Enrollment Is A Two Step Process. The payment process takes place on secure server after which you shift to a separate secure server to complete the membership enrollment. Your payment data and your personal data are kept completely separate.
Member Information Guide and Plan Materials will be supplied via an email web link. Your request authorizes Comprehensive Insurance Agency, LLC, on the behalf of WBA, to charge your credit card or debit your checking account for the initial and subsequent payments to start and continue your WBA membership. Comprehensive Insurance Agency, LLC will charge your credit card or debit your checking account as each modal dues payment comes due. You must provide Comprehensive Insurance Agency, LLC 30 days written notice if you wish to cancel your WBA membership.
After the initial guarantee period has passed, refunds will be based on the following 1st day of the month 30 days AFTER your written request to cancel your membership. Cancellation requests must be in writing or via email. The member will be refunded the unused portion, if any, of dues paid in advance.
Basic Membership with No Insurance Options
Please use the radio buttons below to select your WBA plan.
UNDER CONSTRUCTION
Enrollment Fee
A one time, non-recurring enrollment fee of $10.00 will be added to the first modal dues charge that appears on your credit card or bank statement. Total initial charge will be your chosen plan dues PLUS $10.00. All dues thereafter will be the chosen modal dues.
Agreement and Authorization
I understand that insurance coverage and other member benfits will not become effective, active and available until the 1st day of the 1st month FOLLOWING submission of my application. The ONLY exception to this rule is that applications submitted on the 1st of the the month will be effective immediately.
I understand that I am purchasing a membership in a consumer benefit association.
I understand that I am not purchasing an individual insurance policy but that the membership does include some insurance coverage as part of the benefits package.
I understand that the insurance coverage in the benefits package is for accidental injury ONLY and does NOT cover illness or sickness of any type.
I understand that the insurance in the benefits package coverage does NOT cover any injury incurred prior to the effective date of my membership.
I understand that the accident medical expense insurance in the benefits package pays only for covered reasonable and customary medical expenses, not to exceed the lesser of the chosen benefit or my actual out of pocket expenses.
I understand that the accident medical expense insurance in the benefits package is paid directly to my medical providers unless I supply proof of prior payment.
I understand that the WBA benefits package is NOT health insurance, nor should it be considered a substitute or replacement for health insurance.
(optional ATTD coverage) I understand that benefits are paid only for TOTAL disability as defined in the coverage certificate and confirmed by my attending physician treating the injury. Partial disability is not eligible for benefit payments.
I understand that Exclusions & Limitations Apply and that for complete information I must refer to the member coverage certificate.
I have read, understand and agree to the terms and conditions above. I authorize Comprehensive Insurance Agency, LLC to sign and charge my credit card or debit my checking account according to the plan and payment frequency I have chosen.
I authorize Comprehensive Insurance Agency, LLC the authority to charge my credit card or debit my checking account for all future modal renewal dues as they come due. I will notify Comprehensive Insurance Agency, LLC in writing of my wish to cancel my WBA membership at least 30 days in advance.
KEEP IN TOUCH
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