The JOB LOSS LIFELINE Benefits Program Enrollment Form
To enroll in The JOB LOSS LIFELINE Benefits Program with immediate family benefits plus financial protection unemployment income if you lose your job due to involuntary unemployment. Complete the secure enrollment form on this page as directed and click submit, then process your monthly auto pay enrollment fee of $39.70 on the confirmation page link. When both steps of the registration process have been verified (registration form completed and submitted with the first month's auto pay premium processed). You will receive your complete benefits package with instant family coverage via email within 10 business days of enrollment. Please include your email to continue. All areas must be answered on this application and then submit to complete enrollment. Thank you. The enrollment application must be completed in English.
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Email *
Your Complete Name *
Date *
Please Provide Your Complete and Full Address (Number, Street, City, State and Zip Code) 
Example: (John Doe 1123 Apple Drive Nashville, TN 37207)
 *
Phone Number *
Unemployment Benefit: 

The unemployment benefit of $500 a month for 6 months ($3,000) a year is an automatic benefit for enrolled members ages 18 - 60 that are W2 full time employed at the time of enrollment in the program.  Our unemployment income benefits part of our program only does not cover temporary, seasonal, military, government or state employees, 1099 or Self employed individuals. All members that do not qualify for the unemployment income benefits regardless of age or employment status still qualify for the healthcare benefits and financial services as an enrolled member.  Please indicate employment status by checking a box below.  

Are you a Full Time W2 Employee?
Please Check Yes or No
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Required
Please provide Employer Name and Location if you are a W2 employee / employed: *
Vesting Period: 

There is a 180 waiting period for unemployment benefits. The unemployment benefit only applies to the individual primary enrolled member. All other benefits are immediate family coverage. Please check yes that you understand this program feature
 *
Required
Fraud or Misrepresentation: 

In the event that The JOB LOSS LIFELINE Benefits Program discovers fraud or misrepresentation on the enrollment application process in this program by the enrolling member. The JOB LOSS LIFELINE Benefits Program has no liability for benefits distribution or access to benefits. Paid premiums are non refundable once processed. By clicking yes you agree that you understand the maximum liability The JOB LOSS LIFELINE Benefits Program has when fraud or misrepresentation during the enrollment process is discovered. If we discover a enrolling member was aware that a planned lay off existed during the enrollment process and does not disclose it, it is considered misrepresentation. Please check Yes that you understand and agree to the above information. Thank you
 *
Required
Membership Cancellation: 

In the event that you desire to terminate or cancel your membership requires a 30 day written notice submitted by the member to: info@thejoblosslifeline.com.  Please select yes that you understand this requirement. Thank you
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Required
Agreement of Understanding: 

Please check yes below that you understand and agree to the features, benefits, and requirements to enroll in The JOB LOSS LIFELINE Benefits Program. Thank you
 *
Required
Monthly Auto Pay Enrollment Fee: 

Please check yes below that you understand and agree. All monthly enrollment fees of $39.70 are processed by debit or credit card only. Once submitted enrollment fees are non-refundable. The debit or credit card used must match the enrolled members name. Thank you
 *
Required
Identity Verification and Agreement: 

I understand that by typing my name and clicking on "Submit", I am agreeing to the terms and conditions of The JOB LOSS LIFELINE Benefits Program by Your Payment Guardian  www.yourpaymentguardian.com/terms-and-conditions by electronically signing this document  for verification to legally bind the enrolling member to this application for issuance of coverage and monthly auto pay enrollment premium processing approval. Please click submit below after you type your full name to complete this form. You will be directed to our monthly auto pay enrollment premium portal. Please complete the monthly enrollment premium process to complete the enrollment process. Once You Click SUBMIT Below You Will Be Redirected To A New Page To Set Up Your Monthly Autopay Membership Premium To Complete Your Enrollment. Thank You
 *
A copy of your responses will be emailed to the address you provided.
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