Enroll Check

Payment Methods
We accept Check by Phone (no fee), Money Order, or fill out the enrollment form below.

You may call us. If you enroll over the phone your coverage will take effect immediately. On-line enrollment may take up to 24 hours to become effective. If you mail your payment your benefits will take effect the same day we receive your check or money order.

Privacy Policy

Contact information including email address, telephone number, address, etc. which is provided by the user is used solely for the purpose of completing the order. Financial information including credit card numbers, expiration dates, billing address is used solely to bill the customer for their order. We do not share or sell any information to any third parties.


Primary Enrollee:
Step 1: Fill out the Contact Information and Select a Benefit Plan.
  First Name
  Last Name
  Date of Birth
Month
Day
Year
  Email Address
  Address1
  Address2
  City
  State
  Zip
  Home Phone:
  Work/Mobile Phone:
  Pick a Plan:
  Agent/Broker you spoke to:


Dependants:
Step 2: Enter the Names and Birth Dates of the Family Members who will covered on the plan. Date of Birth should be filled out like this:
    May 18, 2006 should look like this  
    FirstName LastName Date Of Birth in format MM/DD/YY  
     
     
     
     
     
     
     
     
     


Step 3: Fill out the check information that will be used to enroll in the iHaveNoCoverage Plan.
    Check Number:  
    Bank Name:  





    9-digit ABA No:  
    Account Number:  
    Account Holder Name:  


By pressing "Submit" I authorize iHaveNoCoverage.com to duplicate the preceding information into a bank draft form to be used for enrollment in the iHaveNoCoverage.com Benefit Program. I understand that I will receive by mail, a check authorization notice, notifying me that a bank draft has been issued on my behalf for this enrollment, including the $25.00 dollar Registration Fee. I will retain my original check for my record of the transaction.

 


Name
Phone
Email
Comments
 

I HaveNoCoverage.com
355 Plainfield Ave, Suite 6-A
Edison, NJ 08817
Email: Benefits@ihaveNoCoverage.com
Phone: 1-888-TOOTH-51 (888-866-8451)


Available only in NY and NJ

Because the iHaveNoCoverage.com Discount Benefit Programs are NOT Insurance you can go to a provider as often as you like, with no annual maximum !!!