The Jordan Insurance Agency
Speak to a licensed agent (704) 926-7565

Shared Health Alliance/Health Sharing
Plan Application

To signup please complete the quick form below:

Preferred Enrollment Date

Enrollments for the current month will be attempted but cannot be guaranteed in this case your enrollment date will be the 1st of the following month.

Membership Type

Plan Type

Optional Addon Coverage(s)

Primary Member

Contact Information

Spouse

Dependent Child(ren)

Payment Information

Credit Card
Bank/Check
Special Notes or Comments: