Note: An accurate email address is required to deliver and receive benefit information.
By electronically signing below, I hereby certify the above information to be true and correct to the best of my knowledge. I further certify that my electronic signature shall have the same legal effect as an originally signed document under applicable Federal and Florida electronic signature laws.
Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Dealer Login | Distributor Login