Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Will waive $10 Processing Fee if she renews LVM 1/25/19 KSLVM foe her to return my call 1/28/19 KSShe returned my call & I let her know that we will be refunding the $10 processing fee. Refund Pending $10. 1/28/19 KSRefunded. 1/29/19 BH Offered to waive $10 fee after snapengage chat and then called to get payment info they did not want to give me the 3 digit code so are going to send a check in. 01/27/20 JC Member sent EM asking about plan extension due to virus/office closed, tried to call them, rang a few times then silence. Sent EM template. 04/09/20 JC Marlene wants to go to office GM5104 who is not familiar w/ the plan & said they need a fee sched. Calling to explain, following up w/ member. 7/31/2020 EK Spoke w/ Kat at office, they will accept, gave her the member info, reached Marlene & let her know 7/31/2020 EK |
| Membership Type | Family Plan ($139.95) |
| 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. | DC1759430632 |
| Your Name | Gene Snyder |
| Email hidden; Javascript is required. | |
| Phone | (419) 607-3525 |
| Date of Birth | 09/27/1954 |
| List Family Members | Marlene |
| Referred by or Referral Code | ExMail 02/10/20, ExMail 7/23/2021, ExMail 06/13/22, ExMail 8/14/23 |
| Enter Office Code | GM3422 |
| Address | 16958 W. State Route 163 Elmore, OH 43416 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3966 |
| Total | $139.95 |
| 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 | 01/20/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 02/20/2028 |
| Membership ID Number | 1790966605 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 10 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
