Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member said they rcv'd the flyer years ago from the office, DOLR 12/20/2016. Bob said to remove office code JKZ657 from DCmember and not to enter into QB. 5/10/2021 MT Member's husband Craig passed away, wanted to downgrade and receive partial refund. Told her we would since she is within the 30 day MB guarantee. She wanted Ind plan cards to be sent out. Added her to the list 10/7/25 EK Refunded $40. 10/07/25 MT |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1757096348 |
| Your Name | Cecilia Gerdes |
| Email hidden; Javascript is required. | |
| Phone | (815) 861-4538 |
| Date of Birth | 11/23/1952 |
| Address | 2824 W Lincoln Rd McHenry, IL 60051-4526 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4112 |
| Total | $99.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 10/15/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/15/2027 |
| Membership ID Number | 1790604864 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
