Signatory agrees hat this electric signature is valid under the Electronic Signatures in Global and National Commerce Act "ESIGN" --- Pub.L.No. 106-229, 114 Stat, 464 -codified at 15 U.S.C $$$ 7001-7031) and the Uniform Electronic Transactions Act ("UETA") as possible in the state of signature
applied successfully and Amazon.com gift card will be emailed to you by the next business day.
Enter Applicants Name, Email Address, Cell Phone #, Current # of Beds, Current Policy Expiration Date should be the "Effective Date" otherwise use today's date if no current insurance or getting for the first time, Retro Date is explained by hovering over the "?".
All Answers must be correct in order to move to the next screen.
Please type in your Full Name to sign the documents displayed on the screen.
After selecting to pay in full or do down payment, enter your Credit Card information to finalize the purchase of your New Policy. If any questions or changes need to be made prior to clicking to pay, please call us at 805-413-5668.
Once Payment is processed all Confirmation documents will immediately be displayed on this screen and an email will be automatically sent out to the email address provided including a Welcome Letter, Certificate of Insurance, Copies of Signed Documents, a Receipt and the Policy.
Number Of Beds
TERMS OF SERVICE
Description of Ambulatory Classification
Walks unassisted or with the assistance of a cane, no assistance needed to get up from a chair or bed
Uses a walker or wheelchair – no assistance needed to get from a chair or bed (able to transfer or bear weight on their own)
Uses a walker or wheelchair – 1 or 2 persons or hoyer lift needed to get from chair or bed
100% confined to bed, does not get out of bed due to health reasons.