Alliance Access Plan Package

Benefits include legal assistance, ID theft resolution service, and travel emergency assistance. Select annual or monthly billing, and add any optional benefits.

Access Get our top benefits for your whole family in one affordable package.*See details []

Add Optional Benefits:

Dental Savings Plan Save 15-60% on dental procedures and choose from nearly 200,000 providers nationwide.

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Limited Time Offer: Sign up online now and your $25 Activation Fee is waived!

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Join the Alliance

Selected Plan:

Family Plus Plan

$45/month

Optional Health Superpack

+$30/month

Optional Dental Savings Plan

+$12/month

Total

$87/month

Enter your information

First Name * Please enter your first name.

Last Name * Please enter your last name.

Address * Please enter your address.

Address 2

City * Please enter your city.

State * Please enter your state.

Zip * Please enter a valid zip code.

Date of Birth * Please enter date of birth in mm/dd/yyyy format.

Gender * Male Female Please select your gender.

Email * Please enter your email address.

Phone * Please enter phone number.

Membership Start Date * Please enter membership start date.

Note: Start date cannot be in the past or more than 60 days in the future.

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Agent Number* Please enter Agent Number.

If you are applying for an Alliance Family membership, please enter the dependent information so they have full access to membership benefits. If applying as an Individual, please click Continue below

Add Dependent

Enter dependent information

Choose Dependent * Please choose dependent.

First Name * Please enter first name.

Last Name * Please enter last name.

Date of Birth * Please enter date of birth in mm/dd/yyyy format.

Gender * Male Female Please enter gender.

Add Dependent Remove Dependent

Note: Dependents age 19 to 28 must be full-time students.

Age requirements for some benefits may vary. You may list no more than 7 dependents.

Association Rx Card

You may choose dependents to be covered below.

Covered Family Members

(Member)

Program Participant

By enrolling in a plan, I authorize the Association, the Pharmacy Services Administrator and its participating pharmacies to share only information necessary to the fulfillment of prescriptions.

Member is required to pay the entire amount of the discounted rate. The purchase price may vary by drug and by pharmacy. Discounts are available only at participating pharmacies. No portion of the drug cost or dispensing fees for drugs purchased by members under this program is paid by Association Rx Card or EnvisionRxOptions. Pricing and tier positions are subject to change without notice. Pricing and tier positions are only for quantities stated; additional quantities may incur higher costs. May not be available in all states. Members may cancel the Association Rx Card program within thirty (30) days of joining the program, and shall be refunded any and all program fees paid during the initial program membership. Visit www.AssociationRXCard.com for more details on drug pricing and participating pharmacies. For additional information and assistance, please contact Alliance at 1-800-733-2242. This application is not a contract. For complete details, consult your fulfillment materials.

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Join the Alliance

Choose your billing method

Payment schedule * Monthly Annually

Pay yearly and SAVE

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Membership Costs

Value: []
Upgrade Options amount: 0
One-time administration fee []
WAIVED if applying online

WAIVED if applying online
Enter any promotional code here: Re-Calculate the Price
Total First Payment: []

Initial Payment method * Credit Card Electronic Check Please select payment method.

Recurring Payment method * Credit Card Electronic Check Statement by Mail Please select payment method.

Credit card information

Card type * Visa Master Card Please select card type.

Cardholder First Name * Please enter cardholder first name.

Cardholder Last Name * Please enter cardholder last name.

Card Number (enter without spaces) * Please enter card number.

Expiry Month * Please enter expiration month.

Expiry Year * Please enter expiration year.

CVV * Please enter cvv.

Billing ZIP code * Please enter billing zip code.

Relationship to Applicant * Please select relationship to applicant.

For the purpose of honoring debits or credits for collection of initial dues initiated by the Alliance I authorize the Alliance to charge the credit card or debit card account identified as the 'Account' for up to the amount specified and to receive payment of such amount from the Account for payment of initial dues, administration fee and products selected to join the Alliance. I understand and agree that (i) the Alliance membership will not become effective unless and until payment of the full amount of initial dues shall have been received by Alliance, (ii) any charge made pursuant to this authorization will be made for payment of the initial dues & fee only, (iii) reversal or contest of, or objection to, any charge made pursuant to this authorization shall constitute failure to pay initial dues in full which will automatically terminate and void the Alliance membership, (iv) the issuer of any credit card or debit card to be charged pursuant to this authorization is not acting and will not act as an agent of either Alliance or me in accepting and paying the charge authorized hereby and (v) charge will be made immediately upon Alliance receiving this authorization.

Electronic Check - Bank Account Information

Account type * Checking Savings Please select account type.

Check Number (Enter for Initial Payment)

First Name on Account* Please enter first name on account.

Last Name on Account * Please enter last name on account.

Account Number * Please enter account number.

Routing Number * Please enter routing number.

Bank Name * Please enter bank name.

How do I find my account and routing number?

I authorize the Alliance for Affordable Services to debit entries to my account with the depository named for the purpose of honoring charges initiated by the Alliance. This authorization will remain in effect until the company has received notification from me that it is to be terminated in such a time and manner for the company to act on it. I have the right to stop payment of a debit entry by notification to Depository at such time as to afford Depository a reasonable opportunity to act on it prior to charging account. After account has been charged, I have the right to have the amount of an erroneous debit immediately credited to my account by Depository, provided I send written notice of such debit entry in error to Depository within 15 days following issuance of the account statement or 45 days after posting, whichever comes first.

Initial Payment: The Draft will be made immediately upon Alliance receiving this authorization.

Ongoing Payments: If any day above 28 is selected for the membership start date the ongoing draft day will be the 28th.

Dental Plan Disclosure

I understand that will be the covered person on the Dental Savings Plan - Single. If another family member should be covered, please contact Alliance Member Services for change request assistance.

By checking the box and entering my name below, I am indicating my intent to electronically sign this application and warrant that all of the information I have provided is true, complete, and accurate.

Terms & Conditions for Membership Application

I wish to make application for membership in the Alliance for Affordable Services (Alliance). I understand the benefits are offered at the sole discretion of the Alliance and may vary by availability, vendor or state of residence of the Member. Vendors reserve the right to withdraw or change their offers without notice. The benefit descriptions have been taken from the benefit providers’ marketing material and members should carefully examine benefit information before choosing any benefit. The Alliance makes no affirmation of fact or promise relating to the goods and services and specifically disclaims any warranty, expressed or implied, as to the merchantability of the goods and services reflected. To be entitled to Alliance benefits, you must be a member in good standing and dues must be paid current. The Alliance does not verify eligibility status on benefits. Each vendor has the responsibility and right upon claims or services submitted against a benefit to honor or deny service. Monies collected prior to cancellation are non refundable. Should I choose to cancel my membership, I understand I must contact Alliance at 1-800-733-2242 or write to Alliance at P.O. Box 612547, Dallas, TX 75261-2547 or via facsimile to 1-800-847-8889.

I agree with the Terms and Conditions stated within this membership application. * You must agree to the terms and conditions.

Please enter your name below to electronically sign your application.

First Name * Please enter first name.

MI

Last Name * Please enter last name.

Suffix

Please re-enter to confirm your application.

First Name * Please enter first name.

MI

Last Name * Please enter last name.

Suffix

Pressing Submit will process this membership request and charge the account entered.

PLEASE NOTE: If you press the "Submit" button twice, you may be charged twice. After submitting the form, it may take several seconds to process your payment. You will see a confirmation page after your application has been processed.

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Join the Alliance Now and Start Saving

The Alliance Access Plan provides members and their families with extra protection at home and on the road.

ID Theft Resolution Services

Global Emergency Services

Legal Club®

First choose your state so we can show your available options:

Alliance Access Plan Package

Join the Alliance

Enter your information

Enter dependent information

Association Rx Card

Covered Family Members

Join the Alliance

Choose your billing method

Credit card information

Electronic Check - Bank Account Information

Please enter your name below to electronically sign your application.

Please re-enter to confirm your application.

Confirmation

Join the Alliance Now and Start Saving

The Alliance Access Plan provides members and their families with extra protection at home and on the road.

ID Theft Resolution Services

Global Emergency Services

Legal Club®

First choose your state so we can show your available options:

Alliance Access Plan Package

Health Superpack

Dental Savings Plan

Small Business Superpack

Join the Alliance

Enter your information

Enter dependent information

Association Rx Card

Covered Family Members

Join the Alliance

Choose your billing method

Credit card information

Electronic Check - Bank Account Information

Please enter your name below to electronically sign your application.

Please re-enter to confirm your application.

Confirmation

Access Plan Benefits

ID THEFT RESOLUTION SERVICES

GLOBAL EMERGENCY ASSISTANCE

LEGAL CLUB®