Company Enrollment

Primary Contact

Name

First Last

Phone

Email

Title

Example: CEO, Owner

Referral Information

Who referred you?

If you have an affiliate who referred you please type their name here.

Affiliate Number

This field will populate automatically if you used an affiliate link.

Billing Information

Preferred Method of Payment

Card Number*

Expiration Month*

Expiration Year*

CVV or CSC Code*

Please see back of card.

Account Name*

What name is the account in? (Ex: "ABC Sample Business" or name of sole proprietor)

Routing Number*

Account Number*

Authorization Information

Authorized Account Holder*

Yes, I agree

By typing your name below you are giving payment authorization for initial and monthly payment of enrolled plans. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Zionhealth in writing of any changes in my account information within 15 days. This payment authorization is required for plan administration. In the case of an ACH or Credit Card Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Zionhealth or its assigned third party may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.

Monthly Payment*

I authorize the monthly payments of plans that are enrolled for our company.

Enrollment of employees are to be completed after the company setup. Once completed you will receive additional instructions for each employee to enroll in benefits.

Effective Date

Signature