Medicrus

Option #1: Fill out the following online form and a sales agent will contact you shortly.

Name:

Address:

City:

State/Provence:

Country:

Zip/Postal:

E-Mail:

Phone Number:

Additional Comments/Suggestions:

Credit Card Type:

Do you wish to mail a check instead? (*Please see address below)

Yes No

Card Number:

Expiration Date:

3 Digit Card Code:

Name on Credit Card:

Zip Code on Credit Card:

Telephone:

Number Users Requested:

Cost:

$1950 for first user (discounted to $1,400 if paying online by credit card)
$1250 for every addtional user (discounted to $900 if paying online by credit card)

If writing a check, please mail to:

Cignet Health Plan
PO Box 6500
Largo, MD 20792

If we do not receive the check within 10 working days of submission, we will discontinue processing.

Option #2: If you do not wish to fill out our form, call one of our sales persons and they will help you complete your order over the phone. You may call our sales department at 1-800-730-5914 or (if calling from Maryland) 301-423-4551. Hours of business are Monday-Friday, 9am-6pm.

Ask for Gordon Ellison

Option #3: You may also just simply E-mail us at sales@medicrus.com. Please include the following information with your E-mail:

• Your name and/or business

• Your contact information

• Any additional information you wish to include

A sales representative will contact you upon receiving your E-mail.

We look foward to hearing from you!