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www.seniorservicesofgeorgia.com
Patriot America® Plus Group

Please complete the following form in order to begin your Patriot America® Plus Group application.

If you would like to save your application and complete it at a later time, simply click on the "Save Application" button at the bottom of any page of the application after selecting a premium amount and before submitting your credit card information. If you have the Authorization Number and Password from a previous application that was not completed, click here to continue with the previous application.

* Denotes a required field.


 
Age # of Primary Insureds # of Spouses # of Dependent Children
 
 
 
 
 
 
 
 
 
--- Select a Country ---select
Optional File Upload

You have the option to upload a comma-separated value (CSV) file containing the group insureds. Select your file by clicking on the "Browse" button. Then, click on the "Upload" button.