Universal Benefits Order Form

Discount Medical Plan Application


First Name :

Middle Initial :

Last Name :

Sex :	MaleFemale

Address :



City :

State :

Zip/Postal :

E-mail Address :

Date of Birth :

Phone :

Product Information


	One Time Registration Fee $149.05 plus $49.95 monthly. Click here to view our benefits

Payment Information


Method of Payment :	Draft Payment

Name of Bank :

Bank City :

Bank State:

Bank Routing Number :

Checking Account Number :

I agree to the terms and conditions

Form :4140

This plan is NOT Insurance

Discount Medical Plan Organization: New Benefits, Ltd. 14240 Proton Rd. Dallas, TX 75244

This discount card program contains a 30 day cancellation period.

Not available in Florida, Illinois and Kansas.

FL, LA, ND, OK, SC, SD and TX residents: Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after receipt of membership materials. (To be printed as written on all materials)

AR and TN residents: A refund of all fees will be issued if membership is cancelled within the first 30 days. (To be printed as written on all materials)