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Membership Information May 6, 2021 at 11:09:51 AM First Name: Gilbert Last Name: Gomez Address 1: 819 Shaffer St City: Marshfield State: MO Zip: 65706-1954 Phone: (417) 630-1468 Email: [email protected] DOB: 03/12/1976 Gender: M Dependent Information Dependent 1 First Name: Carmen Dependent 1 Last Name: Dutschmann Dependent 1 Relationship: Spouse Dependent 1 Gender: F Agent Information Selling Agent/Agent of Record ILHIS - Dawayne Nance Selling Agency I Life and Health Insurance Services Phone: (800) 219-4152 Email [email protected] SELLING DISCLAIMER The agent/agency above is responsible for marketing and selling the program(s) you are enrolling in today. Please contact the agent if there is an issue with this enrollment. ENROLLMENT CONFIRMATION Thank you for enrolling in a membership program through us! We endeavor to clarify as much as possible the process and obligations between us and have found that providing this confirmation is one of the best ways to start the relationship. Please review and acknowledge your understanding of the below. Once completed, a copy of this form will be provided in the member portal for your records.

Program Information Secure Care - Basic Enrollment one-time $99.00 Program per Month for Member plus Spouse $199.00 Secure Care Basic I acknowledge and agree that the Secure Care plan is a supplement to health insurance, health plans or healthcare sharing programs. I acknowledge this is not major medical insurance and is not a substitute for major medical insurance. I acknowledge and agree that the Secure Care plan offers 100% coverage for ACA preventive services, Primary Care Physician and Specialist Office Visits, and a prescription drug program. I acknowledge that the Secure Care plan includes access to the PHCS Specific Services Network, a national PPO network. I acknowledge and understand that utilizing In-Network providers will help to maximize my savings. Out-of-network providers may charge an additional fee. I acknowledge and understand that the Secure Care plan is subject to limitations and exclusions. It is my responsibility to thoroughly review my plan documents to ensure I understand the plan I have enrolled in and the covered benefits included in the plan INTENDED USE VERIFICATION By enrolling today, I agree and affirm I am enrolling for the sole purpose the programs are intended for and further affirm I was contacted because I provided my contact information for this very purpose. I further affirm I am not enrolling for the purpose of making threats or demands for money by alleging violations of the telephone consumer protection act and/or federal trade commission do not call registry or regulations. I expressly indemnify all parties involved in enrolling in these programs(s) from any alleged violations, or threats of litigation, as it relates to the telephone consumer protection act or federal trade commission do not call registry related violations. MEMBER ACKNOWLEDGMENT I agree that I am signing up for services that include an automatic payment plan. I expressly authorize

I agree that I am signing up for services that include an automatic payment plan. I expressly authorize Premier Health Solutions, LLC, as the Third-Party Administrator for the program(s) I enrolled in today, to automatically debit my bank account or Credit Card on the payment due date provided to collect any and all fees and membership dues for my membership. I acknowledge and agree upon the membership effective date and the initial payment amount (this is comprised of the first month's membership dues and if applicable, a one-time, non-refundable enrollment processing fee). I also acknowledge and agree that my monthly dues will be automatically charged or drafted every month from the credit card, debit card or bank account I provided. Further, I attest that I am the holder of the credit card, debit card or bank account provided. Please Note: You will see \"hmemberbill.com\" on your billing statement. I may cancel automatic payments at any time by calling Customer Service at (214) 436-8883. I understand that I may terminate the scheduled payments by providing written notification to the Customer Service team five (5) business days prior to the next scheduled payment date. This advance notice allows processing time to ensure the termination occurs prior to the next scheduled payment date. Automatic payment termination cannot be guaranteed with respect to notice provided outside of this window. If I am not satisfied with my membership, I may cancel within thirty (30) days from my membership's effective date and I may be eligible to receive a full refund on the monthly membership dues collected for that month. All cancellations must be directed to Customer Service at (214) 436-8883. Cancellations are processed Monday through Thursday from 8 a.m. to 5 p.m. and Friday from 8 a.m. to 4 p.m. Central Time. All cancellation requests must be made five (5) days prior to the billing date in order to cancel the membership for that month. This advance notice allows processing time to ensure the cancellation occurs prior to the next scheduled payment date. Cancellations cannot be guaranteed with respect to notice provided outside of this window. If a cancellation request is received on or after the recurring billing date and the payment has been drafted, the membership will terminate prior to the next billing date and the member will have access to their membership through the next month. The billing department reserves the right to aggressively rebut and dispute any cancellation attempts made by Members via a \"friendly\" fraud chargeback, or similar-especially if no effort has been made to resolve the issue by contacting Customer Service. By utilizing any of the services included in the membership during the first 30 days, I acknowledge and agree that constitutes acceptance of the membership, the program, and their terms and constitutes a waiver of any and all refund rights, including those noted in the foregoing paragraph. I acknowledge and agree that if there is any discrepancy between what I thought the selling Agent told me about the membership I enrolled in and what the materials state, the documentation terms govern. By enrolling in this membership program, I affirm that I can access the internet, and I agree to receive my membership materials through a secure, online member portal, as well as receive important notifications regarding my membership. I acknowledge and agree that I will receive a \"welcome\" email within 24 hours of my enrollment, which will include my membership information. Through the Member Portal, I have the ability to download my materials, and access links for the services included in my membership. IT IS MY RESPONSIBILITY TO READ ALL MATERIALS CAREFULLY AND TO GO OVER ANY QUESTIONS OR CONCERNS WITH MY AGENT, FINANCIAL ADVISOR, A FAMILY MEMBER, OR A TRUSTED INDIVIDUAL WHO MAY BETTER UNDERSTAND SUCH INFORMATION AND/OR DOCUMENTS. Questions can also be directed to Customer Service at (214) 436-8883.

NOTICE OF VOICE CONSENT TO ELECTRONIC TRANSACTIONS, SIGNATURES AND DOCUMENTS I consent and agree to the use of electronic signatures of documents. I consent and agree that if I participated in a recorded verification call, my voice consent shall serve as my signature. I agree I am fully responsible for reviewing this application verification and I have reviewed such application carefully to ensure my full understanding of all provisions of the program. I agree I am fully responsible for reviewing this application. The information in this Enrollment Form is true and complete as of the date signed. CONSENT TO ELECTRONIC TRANSACTIONS I agree that, by using this website, my agreement or consent shall be legally binding and enforceable and the legal equivalent of my handwritten or manual signature. DISCLOSURES Notice to MA consumers: This program does not meet the minimum creditable coverage requirements under M.G.L. c. 111M and 956 CMR 5.00. Almost all enrollments are conducted telephonically and include either a recorded verification script or an e-sign authorization form, which is required with each enrollment. The purpose of the recorded verification call or e-sign authorization form is to ensure that you understand, among other things, what program(s) you are enrolling in, what is included with that program, how much you are paying at the initial time of enrollment, how much you will pay monthly thereafter, and that subsequent monthly payments will be automatically drafter from the credit or banking account you provided. Premier Health Solutions, LLC is a Texas-based Third-Party Administrator, that bills and collects on behalf of numerous carriers and vendors. Premier Health Solutions, LLC operates as a Third-Party Administrator in the state of California under the name PHSI Administrators, LLC. We also do business as a licensed agency under the name PHSI Insurance Agency, LLC in California, and PremierHS, LLC in Kentucky, Ohio, Pennsylvania, South Carolina and Utah. The contact information for the agent/agency who marketed and enrolled you in this program(s) should be located at the top of this document, directly below your information. Electronic Signature I agree that I have a full and complete understanding of the program(s) I am enrolling in. I certify that I am the applicant listed above and I elect to enroll in the following program(s):

Payment Information Secure Care - Basic $99.00 Enrollment one-time $199.00 Product per Month for Member plus Spouse Name: Gilbert Gomez Date: May 6, 2021 at 11:09:51 AM IP Address: 173.22.135.79 System: Mozilla/5.0 (X11; CrOS x86_64 13816.64.0) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/90.0.4430.100 Safari/537.36