Home Care Plans - Nikki Shields Agency

Name *

First

Last

Gender *

Male
Female

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Effective Date *

Hours - Monthly Premiums *

Platinum - 10,000 Lifetime Membership Hours - $ 475.00
Gold - 6,000 Lifetime Membership Hours - $ 295.00
Silver - 3,000 Lifetime Membership Hours - $ 175.00
Bronze - 1,500 Lifetime Membership Hours - $ 95.00
Base (Only Available for Groups) - 600 Lifetime Membership Hours - $ 39.00

Enrolling with a Household Member *

Yes
No

* 10% Discount when enrolling with a household member

Are you able to live independently at this time? *

Are you currently able to preform daily activities such as bathing, dressing, and transferring without assistance from anyone (including family members)? *

Are you aware that the True Freedom Homecare Plans are NOT insurance?

Referring Organization or Individual