Getting Signed Up

You can purchase coverage on your hearing instrument(s) by completing the application and sending it to us along with your payment. Once the information is received and the correct premium is provided, coverage will go into effect. A policy will be issued and sent to you by return mail.

Easy options to apply: Give us a call today at 1-800-821-5471. Submitting application online - If you are applying by credit card, select "Visa/MasterCard/Discover/AMEX", complete the application and submit to us online. Mailing it in - If you are paying by check or money order, select "Check/Money Order", complete and print the application.

Please make checks payable to Midwest Hearing Agency and send to the address below:
Midwest Hearing Agency
3219 Fernbrook Lane N
Plymouth, MN 55447

Midwest Hearing Agency Application

Get Started: Please choose your state for specific pricing.

CONTACT INFORMATION (all fields are required)

Name:

Address:

City:

Zip/Postal Code:
(ex. 55425)

Phone:
(ex. 123-456-7890)

E-mail Address:

INSTRUMENT INFORMATION (complete all fields to best of your ability)

Instrument 1

Manufacturer

Model

Serial Number

Purchase Date

Instrument 2

Manufacturer

Model

Serial Number

Purchase Date

Remote Control

Manufacturer

Model

Serial Number

Purchase Date

COVERAGE OPTIONS (Instrument 1)

Choose the coverage option that meets your needs, select the technology level that matches your devices. See links below for cheat sheet by manufacturer.

Loss & Damage Plan
(In The Ear - Custom devices)

Loss & Damage Plan
(Behind The Ear - RIC/BTE devices)

Loss, Damage & Repair Plan
(In The Ear - Custom devices)

Loss, Damage & Repair Plan
(Behind The Ear - RIC/BTE devices)



Need help determining the technology level of your devices? If you know the manufacturer, you can download the cheat sheet below by manufacturer. Devices are listed by technology level, specific to manufacturer. Having difficulty? We can make the process easy; give us a call at 1-800-821-5471.

Oticon | Phonak | ReSound | Signia/Siemens | Starkey | Unitron | Widex

COVERAGE OPTIONS (Instrument 2)

Loss & Damage Plan
(In The Ear - Custom devices)

Loss & Damage Plan
(Behind The Ear - RIC/BTE devices)

Loss, Damage & Repair Plan
(In The Ear - Custom devices)

Loss, Damage & Repair Plan
(Behind The Ear - RIC/BTE devices)

REMOTE CONTROL COVERAGE

The premiums listed below are per remote. Binaural hearing instruments are considered two hearing instruments. Note: Pricing for Florida residents only is listed between brackets, example ($29).

ADDITIONAL PRICING

Are you looking to insure your remote control? The links above provide specific manufacturer information on remote controls (sold by manufacturer). Can't find your remote? Give us a call.

SWORN STATEMENT & PAYMENT INFORMATION

Please read the following, and check the box for acknowledgement.

I Agree

Name on Card:

Card Number:

Card Expiration:

 

Card CSV:

This is the three digit number on the back of your card.

SecurityMetrics for PCI Compliance, QSA, IDS, Penetration Testing, Forensics, and Vulnerability Assessment
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Date:

Signature:

Denotes required fields

DATE:_____________________SIGNED___________________________________

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: Substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied.)