Instructions Please complete this form to register for the Empower Discount Medical Plan. After we process your request, we will send you a membership packet which contains detailed information about the Discount Medical Plan you selected. Primary Applicant's Information First Name (required) Middle Name Last Name (required) Sex FemaleMale Date of Birth Age Street Address Apartment/Suite # City State AKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY Zip Home Phone Work Phone Ext. Email Spouse Information Will your spouse need coverage? noyes First Name (required) Middle Name Last Name (required) Sex —Please choose an option—FemaleMale Date of Birth Age
