Make Your Monthly Benefit Plan Payments

All LRFA members may pay by check, money order, or simply use the online form below to submit a payment for their currently active Benefit Plans. Confirmation email will be sent to you once we receive payment.

• For International Travel, enroll here
• To pay your Annual Dues only, please use the Membership Renewal form
• If you are not already an LRFA member, please complete Membership Enrollment and applicable Benefit Plan Enrollment prior to using this form.

Please provide the following information: (Red indicates a required field)

Your Information
First Name
Last Name
Middle Initial
Membership #
Telephone
E-Mail Address

Make a Payment
Please enter the applicable fees from your invoice. You may pay for one or more months (please note how many months you are paying for on each plan and multiply fees accordingly).
Medicare Supplemental	Months	Amount Due
M-1   M-Basic   M-2   M-3   M-3d   M-4   M-4d		$
Health Care
A20   A50   A80   B20   B50   B80   C20   C50   C80		$
Prescription Drug Plan
Age 1-17   Age 18-50   Age 51+		$
Supplemental Health Care Plan
Group I   Group II   Group III   Spec. A   Spec. B		$
Emergency Plan for Visitors from Abroad
Plan A   Plan B		$
Mortuary Plan
Basic   A   B   C   D   E   F   G   H   I   J		$
		Benefit Plan Fees: $
		Online payment fee: $
		Donation (optional): $
		Total Payment: $

Questions and Comments:

By submitting this form, I agree to all the terms of the LRFA Benefit Plans.