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2. Expense Types

Expense Type (e.g., Medical*, School, etc.)

Primary % / First Dollar**

Second % / First Dollar**

% /

* For Medical Expenses add one line per child if there is a First Dollar Amount applies per child.
** The First Dollar is the amount that must be reached before the sharing percentages apply (eg., First $250 of Medical expenses are paid by Primary parent)

3. Payment Information

No amounts will be charged on your card during your free trial. Your charges will automatically be charged to your credit card beginning at the billing start date below. If you choose the Annual Option, your card will be charged annual on the anniversary of the billing start date. By submitting this form you are agreeing to these recurring charges. Once you are logged in you will have the ability to cancel at any time, as well as update or change your credit card information.

Subtotal:

Total:


Name on Card:
Card Type:
Card Number:
Expiration Date:
Security Code:
Billing Address:
Billing City:
Billing State:
Billing Zip Code:

4. Confirmation

Thank you. You are all set

We will process your submission and email you when your system is configured for your use. You must confirm your email address by clicking on the link in the email that was sent to you.
Below is a summary of your submission information:

Profile Information

Second Parent Not Included

Start/Effective Date:

Expense Types

-

	Parent*	Register Second Parent (Optional)
First Name:
Last Name:
Email Address:
Confirm Email:
Cell Phone:
Date:		Notify Second Parent after registration is complete
Payment Option:	Monthly ($14.95/mo) Annually ($143.50/yr) 0