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To protect transmission of your information, all electronic transactions for this website are secured by Affinity Group Underwriters using a thawte security certificate issued to affinitybenefits.com. Program not available in South Dakota and Montana.Security Information

Subscriber Information
* Denotes Required Field
 
* Sponsor Number
*First Name  Initial
*Last Name  
*Address
 
*City
*State
*Zip Code
*Home Phone-
Work Phone-
*E-Mail Address
Social Security Number
*Date of Birth
*Gender
Marital Status
Other members of your household to be registered.
NameDate of BirthGenderRelationship
 
 
Desired Billing Cycle
 
Subscriber Only
 $30.00 semi-annually
 $60.00 annually
Subscriber + Family
 $48.00 semi-annually
 $96.00 annually
  
*Effective Date


 

Payment Method
Please Note: A one-time, non-refundable registration fee of $7.00 will be charged to set up your account.
A $3 administration fee is charged on semi-annual subscriptions but is waived for annual payment.
 
*VISA MasterCard
    
 Name on Credit Card  
    
*Credit Card Number 
    
*Expiry Date 
 

I authorize Affinity Group Underwriters to bill my VISA/MASTERCARD for Vital Savings by Aetna® .

This authorization is to remain in full force until  Affinity Group Underwriters has received written notification from me of its termination in such time and in such manner as to afford Affinity Group Underwriters reasonable opportunity to act upon it.

*   I agree to the terms and conditions.