I authorize Professional Risk & Asset Management Insurance Services, Inc., DBA: PRAM, Inc. to debit my Mastercard, Visa, Discover or American Express OR bank account for the amount specified above, as selected from the Rate Table. I understand all amounts indicated in the rate table are monthly rates and I hereby request and authorize PRAM to debit my credit card amount for the proper installment amounts on the due dates of the installments. This authorization will remain in effect for the duration of the Coverage Period elected or until revoked by me in writing. Coverage purchased by credit card is subject to validation and acceptance by the credit card company.

I hereby request prescription drug coverage under a policy administered by PRAM. I understand that payment for this prescription coverage is due monthly and my credit card or bank account will be charged each month on the due date of the premium. I understand that I may terminate the scheduled payments by notifying PRAM in writing at least 31 days prior to the next scheduled payment date. I understand that the information contained herein is a summary of the coverage offered and that I will be emailed a Certificate of Coverage along with my Prescription E-Card upon enrollment. I understand and agree that the insurance agent / broker, if any, assisting with this application is a representative of the applicant. If signed by a representative of the applicant, the undersigned represents his / her capacity to so act. If signed as guardian or proxy of the applicant, the undersigned represents his / her capacity to so act. By acceptance of coverage and / or submission of any claim for benefits, the applicant ratifies the authority of the signer to so act and bind the applicant. FRAUD NOTICE: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

In order for PRAM, Inc. (hereinafter referred to as “we” or “us) to send you your insurance-related documents and communications electronically, to the extent permitted by law, you must first consent to us doing so. The insurance-related documents and communications you will receive in electronic format will have the same contractual force and effect as insurance-related documents and communications sent to you in paper format. We reserve the right, in our sole discretion, to provide any insurance-related documents and communications to you in paper form instead, and / or to discontinue this service or modify the terms of this agreement at our option. If we do, we will provide you with reasonable notice and you will have the option to withdraw your consent at that time. YOUR CONSENT: By checking the accept and acknowledge box and clicking the submit button at the end of this page, you: 1. Consent to receive insurance-related documents and communications, including but not limited to, your policy documents, disclosures, notices, explanation of benefits (EOB), claims documentation, as well as termination and cancellation or non-renewal notices, electronically to the email address you provide to us during your enrollment process instead of receiving these records in a paper format from PRAM, Inc. 2. Agree and acknowledge that your consent is provided and/or obtained in connection with a transaction affecting interstate commerce subject to the Electronic Signatures in Global and National Commerce Act and the Uniform Electronic Transactions Act, or a similar electronic transactions law, as adopted by state law. 3. Agree that the document(s) delivered to you electronically shall have the same meaning and effect as if you were provided a paper document, whether or not you choose to view the document(s), unless you previously withdrew your consent to receive documents via electronic means as provided below. Electronic document(s) are considered received by you at the time you open the email unless PRAM, Inc. receives notice that the email notification was not delivered to you at the email address you provided. YOUR RIGHT TO WITHDRAW YOUR CONSENT: If you consented to receiving insurance-related documents and communications electronically, you may withdraw your consent at any time. After we process your withdrawal of consent, you will begin receiving your insurance documents and correspondence in paper form. You may withdraw consent by emailing PRAM, Inc. at admin@pram.com. Provide your name and contact information so that we can be sure to update our records appropriately. YOUR RIGHT TO RECEIVE PAPER COPIES: You have the right to obtain paper copies of your insurance-related documents and communications at any time. You may request paper copies by emailing PRAM, Inc. at admin@pram.com. Provide your name and contact information so that we can be sure to update our records and appropriately respond to your request. PAPER COPIES FEE: THERE IS NO FEE FOR PAPER COPIES. YOUR OBLIGATIONS: If you consent to receive insurance documents and correspondence electronically, you are responsible for (i) providing PRAM with an updated and active e-mail address through the contact listed below. You should be diligent in updating your email address with us in the event that your address changes; (ii) maintaining or having access to a computer capable of connecting to the internet; (iii) maintaining internet access; (iv) installing software on your personal computer to receive, access, store, and print in accordance with the Technical Requirements listed below; (v) an email service account that allows you to read, write, and send email; and (vi) an active email address. With respect to paperless billing, delays experienced due to the use of this service will not change any payment due date or the potential imposition of late fees. If you do not receive an anticipated document electronically, please email PRAM at admin@pram.com immediately. UPDATING YOUR CONTACT INFORMATION: It is your responsibility to provide PRAM, Inc. with a current, valid email address and to promptly update any changes to this information by contacting PRAM via email at admin@pram.com or calling 800-262-7726 ext 10. You may also access your account online by referencing your welcome email which contains your ID card and other valuable information. UNDELIVERABLE AND RETURN EMAILS: Any e-mails returned as undeliverable will result in a suspension of electronic document delivery and a return to paper copies sent via U.S. mail. TECHNICAL REQUIREMENTS: The following minimal technical requirements are necessary to receive electronic records. A valid email address which can view PDF documents.