BPB Associates

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First Name

Last Name

State

Date of Birth

Gender

Tobacco/Vape Usage

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Cost

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OneShare Classic

Effective Date

Tier Level

ISA (Individual Sharing Amount) Amount

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For individuals and families that are primarily concerned about medical needs as well as hospital concerns. *An annual administration fee of $45.00 is due from each primary member upon their program year anniversary.

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Monthly Administration Fee 30

$30.00 per Month

$30.00

OneShare Application Fee

$125.00 one-time

$125.00

Product:	$155.00
Total	$155.00