Wellness Savings Program

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Disclaimer: THIS IS A DISCOUNT PROGRAM AND IS NONREFUNDABLE. Consumer must understand that the Wellness Savings Card was an employee/employer only program that extended their benefits to the individual market and ONLY FREE to the Colonial employee benefit groups as additional benefits to their employees which is payable thru their employer. All applicants will be monitored thru the website if they are not employees of Colonial employee group enrollment. For more information, please visit our website at https://www.consultwithedmond.com/insurance-brokerage/wellness-dental-and-vision/.

Name *

Email *

Address *

Phone number *

DOB *

YYYY

Family Information

Name, date of birth, and relationship

Family member 1#

Family member 2#

Family member 3#

Family member 4#

Family member 5#

Dentist Name & Address

Membership

Sales Tax: 5%. $10 discount for Medicare.

Type of Membership *

$ 75 per individuals

$ 130 Family of 2

$ 180 Family of 3

$ 250 Family of 4

Other:

Method of Payment *

Visa

Mastercard

Discover

Invoice Me (Payment is due upon receipt of email)

Card Number

Card Expiration

CVV

Billing Zip Code

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