A copy of the member's paid receipt must accompany this application. Please upload a digital copy at the end of this form by clicking the 'upload copy of receipt' button. If you need assistance submitting your receipt, please call the office at 800-537-3913 or 765-569-3133. Receipts can also be faxed to 765-569-3360 or mailed to Customer Service Dept, 119 West High Street, Rockville IN 47872.