IndividualsEnrollingPageMed

Self Employed Enrollment

  • STEP 1: Download the CoOp Membership Agreement by clicking the first button below and saving it on your desktop or in a folder. The form is an interactive PDF which may be filled out electronically before clicking “Submit Forms Here” button at the bottom of this page. If you prefer, you may download, print, fill it out by hand, and scan before submitting.
  • STEP 2: Pay your annual CoOp Membership Fee by clicking the second button.
  • STEP 3: Click to download all remaining forms: Employer Group Information Form, ACH Authorization, W-9, Employer Freedom Plan Enrollment Application, and the Cost Calculator. Save them on your desktop or in a folder. The forms are interactive PDFs and may be completed electronically, or if you prefer, you may print, complete, sign all forms before submitting them by clicking the “Submit Forms Here” button below. Please Note: the W-9 must be printed, signed by hand, and scanned before submitting. The ACH Authorization must include a cancelled check.
  • STEP 4: Once you’ve completed and signed all forms, you’re ready to upload them. Click the “Submit Forms Here” button, which will redirect you to the Regional Care, Inc. portal. Click the “Add Files” button, select all the files you want to upload, and click the Open button. Fill in your name, email address, and any comments you want to add in the pop-up window, and click Ok. Then click the Upload button to begin the quick uploading process. A small window will briefly appear at the upper right to notify you when your upload is complete.
SBA CoOp Membership Agreement

Download, complete, and then submit
the CoOp Membership Agreement

Click Here to
Pay Your CoOp Membership Fee

Your CoOp Membership will renew annually
on January 1 of each year.
*All Sales Are Final

Group
Information Form

Completed for each new Member – Employer client

 

ACH Recurring
Authorization Form

Completed for each new Member client who
will be paying their own respective premiums.

W-9
Form

Completed by each new enrolling Member/Employee

Cost
Calculator

Completed by each new enrolling Member/Employee

Employer Freedom Plan
Enrollment Application

Completed by each new enrolling
self-employed person or employee

Submit Forms
Here

After downloading, completing and signing all forms,
click here to submit.