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Sign up for the Dollar-a-Day Program.

Dollar a Day Program - Closeup View of a Woman Holding a Toy Car on Top of One Dollar Bills in her Hands

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Do you need dollar-a-day insurance? Watch the video to learn more and sign up using our form below.

Learn more about how you can get a dollar-a-day insurance, which offers some coverage for emergency medical treatment in an auto accident. Only available for eligible New Jersey residents with active Medicaid benefits.

Dollar-a-Day Program

Please fill out the form below- after submitting someone from our office will call you during business hours to issue* your dollar-a-day policy during business hours.

*You must pay on a credit or debit card and E-sign your application before your policy will go into effect.

There is a possibility that we will not be able to issue your dollar-a-day policy the same day you submit even if it is during business hours due to agent availability.

Make sure all photos submitted are up close and clear.

If you do not have the registration or title, you can submit the bill of sale. *Valid registration preferred.

"*" indicates required fields

Name
Address
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 300 MB.
Upload the file here.
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 300 MB.
Registration Preferred. Upload the file here.
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 300 MB.
Upload the file here.
Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 300 MB.
NJ Health Benefits ID Card with 16 Digit CCN# Starting with 777. Upload the file here.
Will you be paying in full or installments?
This field is for validation purposes and should be left unchanged.

Prefer to speak with someone from Affordable Insurance Agency LLC?
Contact us directly.

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