Family Healthcare Discount Plan

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Application

STEP 1: Member Information

	First Name:
	Last Name:
	Address Line 1:
	Address Line 2:
	City:
	State:
	Zip Code:
	Phone:	- -
	E-Mail:
	Social Security #:	- -
	Referred By: (optional)
	Referrer's E-Mail: (optional)

STEP 2: Choose The Plan That's Right For You

Family Plan

$179.95/year*

$15.45/month*

The TSP Family Plan includes discounts on the five most frequently requested benefits and should satisfy the requirements of most families.

Special Benefits in the Family Plan include discounts on:

� Pharmaceutical drugs
� Dental
� Vision
� Hearing and
� Chropractic care

The cost of the Family Plan is only 179.95 annually and coverage includes all members of your immediate houshold, regardless of how many children you have.

Healthy Living Plan

$249.95/year*

$20.95/month*

The Healthy Living Plan includes all of the benefits of the Family Plan plus it has the following benefits:

� Physicians Referral Service
� Alternative Medicine
� Vitamins and Nutritional Supplement

The cost of the Healthy Living Plan is 249.95 annually and coverage includes all members of your immediate household, regardless of how many children you may have.

Independent Living Plan

$199.95/year*

$16.75/month*

The Independent Living Plan includes all of the benefits of the Family Plan plus it has the following benefits:

� Medical Information Telephone Service
� Durable Medical Equipment
� Extended Care / Home Healthcare

The cost of the Independent Living Plan is 199.95 annually and coverage includes all members of your immediate household, regardless of how many children you may have.

Explorer Plan

$189.95 /year*

$15.85/month*

The Explorer Plan includes all of the benefits of the Family Plan plus it has the following benefits:

� Discount Travel
� Travel Emergency

The cost of the Explorer Plan is 189.95 annually and coverage includes all members of your immediate household, regardless of how many children you may have.

STEP 3: Enter Your Billing Information

	Card Type :
	Card Number : (no dashes)
	Card Expiration : (example: 04/06)

	Payee's First Name:
	Payee's Last Name:
	Payee's Address Line 1:
	Payee's Address Line 2:
	Payee's City:
	Payee's State:
	Payee's Zip Code:

*there is a one-time enrollment fee of $4.95 to cover the cost of order processing, your membership kit, postage and handling

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