This is an authorization to allow the Third Party Administrator to deduct the fees associated with the products
you have purchased. There will be a bank draft for the one time registration fee of $0 in addition to the dues
of $0 on 11/28/2018. Monthly
dues will be automatically drafted thereafter starting on 06/06/2016.
You have selected the following products:
I, [Name Not Entered Yet] authorize the charge to my account for the amount indicated above at the above indicated frequency. I understand that I can cancel the product at any time and incur no further charges. I agree to notify the merchant in writing of any changes in my account information or termination of this authorization 15 days prior to the next due date of the charges. For ACH debits to my checking/savings account, I understand that because this is an electonic transaction, these funds will be withdrawn from my account as soon as the above noted transaction date. I acknowledge that the origination of ACH transactions to my account my comply with the provisions of US Law. I understand that cancellations must be made in writing and I will not dispute merchant recurring billing with my bank or credit card company, so long as the amount corresponds to the terms indicated in this contract.
I hearby apply for enrollment in Aegis Administrative Services Discount Benefits Plan. I understand that acceptance of this enrollment is guranteed.
I understand that the earliest ny enrollment can become effective is the 1st day of the following month after aegis's receipt of the complete enrollemnt
form and the first month's payment. As a member of aegis Administrative discount benefit plan we understand that your trust in us is ohe of our most important assets.
In order to preserve that trust, we want you to understand our information practices and your rights to ask us not to share certain information about you. As a member
of this plan we want you to know the following: Aegis Administrative Services, will not share any information with any firm or individual not affiliated with Aegis
Administrative Services, and will not sell or rent members names with any firm or individual.
THIS IS NOT INSURNACE
THIS IS A DISCOUNT BENIFIT
This discount program has a 30 days cancellation period. discount benefit are not insurance, and are not intended as a substitute for insurance.
Member shall receive a full refund of membership fees, excluding registration fee, if membership is cancelled within the first 30 days after receipt
of membership materials.
By clicking the submit button, you will be enrolled in the selected products and your credit card or checking account will be billed for the amount selected. By clicking the button you also agree that all information provided is accurate and complete.