I understand I have no obligation to pay for the Member-only NO-COST to me Patriot Protection Plan.
The undersigned hereby agrees to appoint CSO’s President and/or Secretary the continuing proxy to vote for the applicant at any annual, regular or special meetings of the Company at which the applicant is not present. The annual meeting of members shall be held each year in the home office (1212 North 96th Street, Omaha, Nebraska 68114) on the second Tuesday of January at 10:00 a.m. This proxy shall remain in effect until revoked in writing and voting in person or until the insurance plan applied for is no longer in effect.
THIS IS A LIMITED BENEFIT HEALTH COVERAGE POLICY AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES.
Fraud Warnings:
WARNING: Any person who knowingly, willfully, or with intent presents materially false, incomplete, misleading or fraudulent information for the purpose or intent of deceiving or defrauding an insurer is guilty of a crime and may be subject to imprisonment, fines, denial of insurance and civil penalties.
I authorize the Plan Administrator to process my initial and future payments utilizing the information I have provided. I understand that my payments will be processed on the due date or the business day prior to my due date and will continue to be charged to my provided account until the Plan Administrator has received and has had reasonable time to act on my request to cancel by telephone at 1-877-672-3006. A processing fee will be included in the total amount charged for each automatic account billing. I understand these terms and authorize recurring payments.
