Your Payment Guardian - The JOB LOSS LIFELINE Enrollment Form
To enroll in The JOB LOSS LIFELINE Benefits Program by Your Payment Guardian with access to family healthcare benefits and financial services plus $3,000.00 in job loss income protection 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 the next step of the enrollment process. Thank you. The enrollment application must be completed in English.
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Email *
Please type the (Person's Name) or (Email Address) that shared The JOB LOSS LIFELINE Benefits Program by Your Payment Guardian with you and sent you to this enrollment page to enroll before moving to the next section. Thank You
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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 *
Job Loss Income Benefits: 

The job loss income benefit of $500 a month for 6 months ($3,000) a year is an automatic benefit for enrolled members ages 18 - 65 that are full time W2 employed at the time of enrollment in the program.  Our job loss income benefits part of our program only does not cover temporary workers, seasonal workers, part time workers, military, government employees, state employees, 1099 or self employed individuals. All members that do not qualify for the job loss income benefits regardless of age or employment status still qualify for the healthcare benefits, financial services and enrollment representative opportunity as an enrolled member.  Please indicate employment status by checking a box below.  

Are you a Full Time W2 Employee ages 18 - 65?
Please Check Yes or No
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Required
All representatives are required to be enrolled members ($39.70 monthly) regardless of employment status or age. Please check "Yes" below that you understand this representative requirement. (If you are enrolling as a member only and not a representative please check the Does Not Apply box below)
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Required
Please provide Employer Name and Location if you are a W2 employee / employed: *
Job Loss Income Waiting Period: 

There is a 180 day waiting period (6 months) for job loss benefits access. The job loss income benefit only applies to the individual primary enrolled member. All other benefits are family coverage access. Please check yes that you understand this program feature
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Required
Fraud or Misrepresentation: 

In the event that The JOB LOSS LIFELINE Benefits Program by Your Payment Guardian discovers fraud or misrepresentation by the individual enrolling in the  program. Your Payment Guardian has zero liability for payment of (job loss income benefits or access to family healthcare and financial services benefits). If it is discovered that a planned lay off existed. The job loss income benefits will not be approved. Please check Yes that you understand and agree. Thank you
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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: connect@yourpaymentguardian.org.  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 Your Payment Guardian. Thank you
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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
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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 redirected 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
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A copy of your responses will be emailed to the address you provided.
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