Desired Benefit Access*Select Access Level1 Active Benefit2 Active Benefits3 Active Benefits5 Active BenefitsManage Your Active Benefits1st Active Benefit*Select BenefitDental Care SavingsOrthodontist SavingsTele MedicineHealthcare ConciergeEye & Vision CareImaging & Advanced ImagingLab and Blood TestingChiropractic CarePodiatrist CareHearing & Hearing AidsDiabetic Care & ManagementLife Event CounselingMedical Advocacy / Bill NegotiationRoadside AssistanceTax & Accountant ServicesPet Care SavingsLegal Care & Services2nd Active Benefit*Select BenefitDental Care SavingsOrthodontist SavingsTele MedicineHealthcare ConciergeEye & Vision CareImaging & Advanced ImagingLab and Blood TestingChiropractic CarePodiatrist CareHearing & Hearing AidsDiabetic Care & ManagementLife Event CounselingMedical Advocacy / Bill NegotiationRoadside AssistanceTax & Accountant ServicesPet Care SavingsLegal Care & Services3rd Active Benefit*Select BenefitDental Care SavingsOrthodontist SavingsTele MedicineHealthcare ConciergeEye & Vision CareImaging & Advanced ImagingLab and Blood TestingChiropractic CarePodiatrist CareHearing & Hearing AidsDiabetic Care & ManagementLife Event CounselingMedical Advocacy / Bill NegotiationRoadside AssistanceTax & Accountant ServicesPet Care SavingsLegal Care & Services4th Active Benefit*Select BenefitDental Care SavingsOrthodontist SavingsTele MedicineHealthcare ConciergeEye & Vision CareImaging & Advanced ImagingLab and Blood TestingChiropractic CarePodiatrist CareHearing & Hearing AidsDiabetic Care & ManagementLife Event CounselingMedical Advocacy / Bill NegotiationRoadside AssistanceTax & Accountant ServicesPet Care SavingsLegal Care & Services5th Active Benefit*Select BenefitDental Care SavingsOrthodontist SavingsTele MedicineHealthcare ConciergeEye & Vision CareImaging & Advanced ImagingLab and Blood TestingChiropractic CarePodiatrist CareHearing & Hearing AidsDiabetic Care & ManagementLife Event CounselingMedical Advocacy / Bill NegotiationRoadside AssistanceTax & Accountant ServicesPet Care SavingsLegal Care & ServicesPayment AuthorizationPromotion CodeOne Time Card Fulfillment Charge* Price: $0.00 The Onetime Printed Card Fulfillment Fee is waived for all members who enroll before December 31, 2015.Total Due Today $0.00 This page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Benefit Card PersonalizationName One Card* First Last Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Your mobile phone number become your Sociallity Member Number.Email Address* User Name*Password* Enter Password Confirm Password Terms and Conditions* I hereby authorize Sociallity Benefits to charge my credit card or debit card the amount due for this benefit activation II hereby authorize Sociallity Benefits to automatically charge my credit card or debit card the monthly benefit access fees. I understand that this charge will automatically be made until such a time that I elect to cancel my active benefit(s). I hereby acknowledge and understand that I may cancel the benefit program at any time without penalty. Upon canceling my benefit, Sociallity will immediately discontinue charging the monthly benefit access fee. Depending on the date of the cancellation, I may qualify for a refund of a portion of the access fee paid during the month of my benefit access cancellation taking place. I hereby acknowledge, agree to, and accept the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, the Sociallity Benefits Terms and Conditions, and the Sociallity Healthcare Coin Terms and Conditions.
