Create New Customer Account

Contact Information

First Name

Last Name

Confirm Email

Cell Phone

Subscribe to our marketing emails ()

Subscribe to our text messages ()

I agree with the terms of service and the privacy policy

New Password

Password

Password must be at least 8 characters long, contain at least 1 upper case letter, at least 1 lower case, and at least 1 number.

Confirm Password

Address Information

Address Line 1 (P.O. Boxes are not allowed)

Shipping Address cannot be P.O. Box

Address Line 2

City

State

Zip

Personal Information

Date of Birth (Must match date provided by Employer)

Employment Information

Employee ID

If you do not know your Employee ID, please contact your HR Department or access your HR/Payroll system of record to retrieve.

Backup Payment Method

Card Holder Name

Payment Card Number

Expiration Date

Card Verification Number

Billing Zip Code

Bank Account Information

Routing Number()

Checking Account Number()

Social Security Number

I authorize BenefitsMe to utilize the above account and card information to collect any amounts owed in the event my payroll deduction is suspended or terminated for any reason. I further authorize BenefitsMe to obtain a credit report on me. This authorization will not affect my FICO credit score and all types of credit are acceptable. Good Credit is NOT required.

Congratulations, You’ve been approved!

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