Online Enrollment Form

To be eligible, all persons listed on the enrollment form must be permanent residents of the listed address.


Please complete the enrollment form TODAY so that we may process your request immediately. Plan benefits will begin on the 1st day of the month following receipt of your enrollment. If today is the 1st of the month, your benefits will start TODAY.

If you have any type of medical emergency, DO NOT delay treatment. Such a delay could result serious harm or illness, and might result in expenses that exceed any savings realized by waiting for the plan to go into effect.

Once you have completed the enrollment form, you will be directed to setup an online portal to manage your membership. Membership access will provide detailed instructions and contact information to help you file a claim.

DIPerks uses a true Secure Enrollment system to assure the confidentiality of your personal information.

Member Discounts will be available on the 1st day of month. Your request authorizes DIPerks, LLC on behalf of WBA, to charge your credit card for the initial and subsequent payments to start and continue your WBA membership. DIPerks, LLC will charge your credit card as each model dues payment comes due.

After the initial guarantee period has passed, refunds will be based on the following 1st day of the month 30 days AFTER your written request to cancel your membership. Cancellation requests must be in writing or via email. The member will be refunded the unused portion, if any, of dues paid in advance.

These WBA plans are NOT AVAILABLE to residents of Arkansas, Kansas, Maine, Maryland, New Mexico, North Carolina, Oregon, South Dakota, Utah or Washington.

Select Your Plan

14 Day Elimination Plans


30 Day Elimination Plans


Enrollment Fee

A one time, non-recurring enrollment fee of $10.00 will be added to the first modal dues charge that appears on your credit card or bank statement. Total initial charge will be your chosen plan dues PLUS $10.00. All dues thereafter will be the chosen modal dues.

Billing Summary

One time Enrollment Fee:
To be billed today/monthly:
Total Billed Today:

DIPerks offers you a 30 day money back guarantee. If for any reason you decide to cancel your membership within the first 30 days after application or effective date (whichever is later), we will give you a full refund of your association dues and enrollment fee, no questions asked.

About You

Please enter your information below:

Date of Birth and Gender
Billing Information:

Agreement and Authorization

I understand that insurance coverage and other member benefits will not become effective, active and available until the 1st day of the 1st month FOLLOWING submission of my application. The ONLY exception to this rule is that applications submitted on the 1st of the month will be effective immediately.

I understand that I am purchasing a membership in a consumer benefit association.

I understand that I am not purchasing an individual insurance policy but that the membership does include some insurance coverage as part of the benefits package.

I understand that the insurance coverage in the benefits package is for accidental injury ONLY and does NOT cover illness or sickness of any type.

I understand that the insurance in the benefits package coverage does NOT cover any injury incurred prior to the effective date of my membership.

I understand that benefits are paid only for TOTAL disability as defined in the coverage certificate and confirmed by my attending physician treating the injury. Partial disability is not eligible for benefit payments.

I understand that Exclusions & Limitations Apply and that for complete information I must refer to the member coverage certificate.

I have read, understand and agree to the terms and conditions above. I authorize DIPerks, LLC to sign and charge my credit card according to the plan and payment frequency I have chosen.

I authorize DIPerks, LLC the authority to charge my credit card for all future modal renewal dues as they come due. I will notify DIPerks, LLC to cancel my WBA membership.