Gig Safety Plus Application

An Alternative Form Of Access?

Interested in our innovative community share program that can save you from bankruptcy and give you access to top-quality healthcare at affordable prices? Simply fill out the form below, and a representative will reach out to you within five business days. Please note that this program is not available in all states and to all users, so we will have to evaluate your application.

First Name

Middle Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone Number

Do you use nicotine and/or tobacco? This includes vaping, cigarettes, cigars, pipes, and any other nicotine-containing products.

Yes No

Social Security Number: XXX-XX-XXXX

Date of Birth

Is there a spouse you want to have access?

Yes (If yes, please re-submit this form with your spouse's information). No

Are there minor dependents you want to have access?

Yes (If yes, please re-submit this form with each of your minor dependent's information). No

I am interested in receiving future updates about other ways to get access to lower-cost healthcare solutions.

How did you hear about us?

Call

(888) 644-4723

email

info@gigsafety.net

About

We solve healthcare for the Gig Economy by leveraging the latest technology and innovation in healthcare coupled with the premise that smart technology, full transparency, and leveraged negotiation are the keys to controlling healthcare costs.

Gig Safety Plus Application

An Alternative Form Of Access?

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email

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