ASSOCIATION MEMBERSHIP ENROLLMENT ACKNOWLEDGEMENT I hereby enroll for membership in the Med Sense Guaranteed Association (MSGA). As a member of MSGA, I understand that I will be able to access membership products, benefits and services. I acknowledge that member benefits are subject to change without notice.

Limited Benefit Medical Insurance Benefits:	BASIC500	PLUS750	CHOICE1000	MAX1500
Hospital Indemnity	X	X	X	X
Surgery	X	X	X	X
Anesthesia	--	X	X	X
Doctor Office Visits (Injury or Illness)	X	X	X	X
Doctor Office Visits (Wellness)	--	X	X	X
Diagnostics X-rays, Labs	--	X	X	X
Emergency Room Visits	X	X	X	X
Ambulance	X	X	X	X
Accidental Injury	X	X	X	X
Accidental Death and Dismemberment	X	X	X	X
Prescription Drug / Discount Vision	X	X	X	X

X Included

-- Not Available

Individual	BASIC500	PLUS750	CHOICE1000	MAX1500
Monthly Premium	$79.50	$149.50	$199.50	$259.50
One time enrollment fee	$25.00	$25.00	$25.00	$25.00
*Add monthly administration fee	$12.50	$12.50	$12.50	$12.50

Individual+1	BASIC500	PLUS750	CHOICE1000	MAX1500
Monthly Premium	$173.29	$299.50	$399.50	$561.84
One time enrollment fee	$25.00	$25.00	$25.00	$25.00
*Add monthly administration fee	$12.50	$12.50	$12.50	$12.50

Family	BASIC500	PLUS750	CHOICE1000	MAX1500
Monthly Premium	$227.65	$399.50	$499.50	$699.50
One time enrollment fee	$25.00	$25.00	$25.00	$25.00
*Add monthly administration fee	$12.50	$12.50	$12.50	$12.50

*Monthly costs include Med Sense Guaranteed Association, discount RX benefits and discount vision benefit fees of $9.25 for individual, $14.95 for individual plus one and $19.25 for a family. These are not insurance benefits nor are they affiliated with United States Fire Insurance Company.