UCES Protection Plan

Protection For Your Financial Future

1. Enrollment Information

SSN*

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DOB*

Title*

Gender*

First Name*

Middle Initial

Last Name*

Address*

APT / Suite

City*

State*

Zip Code*

Email*

Verify Email*

Cell Phone*

Alt. Phone

2. Payment Information

If you are using a prepaid debit card, it must be registered with the issuing card company. Please refer to the instructions on the back of your card for registration instructions. Registration will require the submission of your Name, Address and Zip. The address on your billing information must match the address that you’ve used to register your pre-paid card.

Amount Paid

$188 (onetime setup fee $99 & Monthly Fee $89)

Card Type*

Card Number*

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Expiry Date*

CVV Code*

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Billing address and credit card address must match in order to proceed

Card First Name*

Card Last Name*

Billing Address*

City*

State*

Zip Code*

3. Terms & Conditions

Please Review and Check Off on the Following Terms:

Please accept my application and enroll me in the UCES Protection Plan. I understand that an automatic payment of $89 will be made from the account provided above each month

I have read and understand the Terms and Conditions of Enrollment.

Pref. language*

English Spanish

Agent ID*

Agent Name*

Address Verification

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