Payments Order Number Policy payment information How would you like to pay for your coverage? If you have questions about this form, please contact us at PAYMENTS@OpenCareSeniors.com or call 321-300-1446 INSURED - First Name * Middle Name Last Name * Choose the DAY OF THE MONTH for premium payments * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Benefit amount Monthly premium (call to confirm amount if not known) Policy number (if known) Insured SSN# Is the PAYOR same as insured? YES NO BILLING ADDRESS (include Street, City, State, zip) * PAYMENT METHOD * Pay by CARD Pay by BANK DRAFT Phone (payor) * Email (Payor) *
