Identity Theft Enrollment

MEMBER INFORMATION
Member Number
First Name*
Last Name*
Address*
Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Home Telephone Number
Cell Phone Number
Email Address*
SELECT YOUR PROTECTION PLAN
Select Your Plan:*
- Plan A - $24
- Plan B - $36
FORM AGREEMENT & SUBMISSION
Agreement: I am agreeing to purchase the Identity Resolution Services as selected electronically. I understand that a Welcome enrollment kit will be sent to me. I, also, acknowledge that the services are non-transferable and non-assignable and that services are automatically renewed unless cancelled in writing 10 days prior to service renewal date. I can withdraw my electronic consent within 10 days by sending a written request to (OOIDA, Attn: Life & Health Benefits Department, 1 NW OOIDA Drive, Grain Valley, MO 64029). However in the event I withdraw my electronic consent I understand that this agreement to provide services will be cancelled and I am not entitled to utilize the services referenced.
YOU MUST SELECT THE CHECKBOXES BELOW AND SIGN:*
- I UNDERSTAND AND AGREE

MEMBER INFORMATION