Dental Premium Health Select

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HMO Dental Plan Starting at $39.95

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Dental Premium Health Select

  1. 1. Premium Health SelectHealth & Dental Care SolutionS 06597/CA-FL
  2. 2. Premium Health SelectOur mission has always been to provide our members with a cost-effective and simple-to-use healthcare program, backed by thebest customer service in the industry. That is why each of our plans has been carefully created with select services and groupbenefits to offer you an exceptional healthcare value at an affordable cost.Sign-up today and enjoy the healthcare solution you have been seeking with Premium Health Select: DENTAL HMO Dental insurance coverage for you and your loved ones with no deductible, no annual or lifetime dollar maximum. Receive simple-to-use, quality dental services at affordable out-of-pocket cost –– you no longer have to grit your teeth at outrageous dental fees!Hospital patient advocacyWe work hard to lower your hospital bills!legal servicesLegal advice at your fingertips!pet careProtect that “other” family member, your pet!$50 pHysician office visit reimbursementDon’t use emergency rooms for primary care! Visit your Physicianup to 5 times per family member per year!$5,000 accidental inJuryYou will be protected from virtually ANY injury!$10,000 accidental deatH & dismembermentProtect your family from unexpected expenses!emergency travel assistance100% coverage for worldwide air ambulance needs up to $100,000!06597/CA-FL AWIS049_PremIumHeALTHSeLeCT_CAFL | reV:7.20.2011
  3. 3. SPonSor & enroller inForMation For oFFice USe only 2 3 4 5 6 7Sponsor Name: _____________________ Daniel Mejia 43848IMA/MSA #: ________________________ Date: ________________________________ 10878 Westheimer Rd., Suite # 191, Houston, TX 77042 Daniel MejiaEnroller Name: ______________________ Phone: 1.866.365.5829 • Fax: 1.866.837.4556 Dental office #: _______________________ 43848IMA/MSA #: ________________________ MeMBer aPPlication Dental office name: ___________________ PreMiUM HealtH Select Dental office Phone: ___________________ Plan ServiceSFeeS anD DUeS: •  Dental HMO* •  Pet Care •  $10,000 Accidental Death &  •  Hospital Patient  •  $50 Physician Office Visit  Dismemberment † •  Individual Monthly Dues: $79.95 Advocacy Reimbursement** •  Emergency Travel Assistance § •  Family Monthly Dues: $119.95 •  Legal Services •  $5,000 Accidental Injury † •  One-Time Application Fee: $60.00 MeMBer inForMation (Please Print Clearly)Last Name: ___________________________ First Name: _______________________________ M.I.: _________________ D.O.B:________________Mailing Address: _____________________________________________________________________________ Apt #: ________________________City: _______________________________________________________________ State: ________________________Zip: ___________________Gender: ____________________________________________________ Language: _____________________________________________________E-mail: ____________________________________________________ Home Phone #: _________________________________________________Cell Phone #: ________________________________________________ Work Phone #: __________________________________________________Fax #: _____________________________________________________ Beneficiary: ____________________________________________________ MeMBer’S FaMily inForMation (Please Print Clearly)Spouse’s First Name: ______________________________ Last Name:__________________________________________ D.O.B: _________________Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________(For additional dependents, add additional sheets) Billing inForMation (Please seleCt only one method oF Payment)one-time application Fee: $ _______________Monthly Dues: $ ______________ optional Service: $_______________ total: $ _______________Bank Draft or Debit: (check only one) Checking SavingsName of Account Holder: ____________________________________________ Bank Name: _______________________________________________Bank Transit #:____________________________________________________ Bank Account #: ____________________________________________credit card: (check only one) VISA American Express Discover MasterCardName of Account Holder: _____________________________________________________________________________________________________Account #: ________________________________________________________ Expiration Date: _______________________ CVV2 #: _____________(The CVV2 # is the last 3 digits next to the signature line on the back of your credit card; or the 4 digits after your account # for American Express)I have read the terms, conditions, and disclosures on the back of this application and authorize American Workers Insurance Services or its designatedattorney-in-fact to electronically draft my account or bill my credit card indicated on this application for my one-time initial application fee and my membershiprecurring dues.Check this box if you are paying for this membership and are not the member.X________________________________________________________________________________________ Date: _________________________Signature of the Depositor or credit card Holder (must be signed by employer if employer is paying the membership dues.)06597/CA-FL AWIS049_PremIumHeALTHSeLeCT_CAFL | reV:07.20.2011
  4. 4. agreeMent oF terMS & conDitionS (PleaSe Print clearly)I, the customer, understand that the discount portion of the American Workers Insurance Services (AWIS) Program is NOT INSURANCE and the limited associationgroup insurance benefits are NOT COMPREHENSIVE INSURANCE, and that I am applying to become an AWIS member. _________(Initial).I understand that I am joining American Workers Insurance Services (AWIS) as a Premium Health Select member. I further understand that by joining the program,I am automatically eligible to become a member of the National Association of Preferred providers (NAPP). As a member of the NAPP association and at noadditional cost to me, I am entitled to limited group dental insurance benefits after a waiting period; for specific benefit waiting periods, call Member Services at1.866.365.5829. I understand that participation in the NAPP association is voluntary.I understand that I have purchased a membership in AWIS from _________________________________ , IMA/MSA # ____________________________ . Daniel Mejia 43848I, the customer, may cancel my membership at any time. However, if I cancel prior to midnight on the thirtieth (30th) day after the date of the postmark on themember fulfillment package plus five (5) days, I am eligible for a refund of my membership dues. To cancel I must notify AWIS in writing of my intent to cancel.I have read and understand the cancellation policy and disclosures set forth below.X ________________________________________________________________________________________ Date: _________________________Signature PrograM DiScloSUreSThe program‘s services and group benefits are marketed by American Workers package, plus five (5) days, and will receive a refund of membership dues paid.Insurance Services (AWIS), a licensed insurance agency. The one-time enrollment fee is held as a non-refundable processing fee. The cancellation effective date shall be the date of the postmark if sent by mailcancellation Policy: American Workers Insurance Services membership and the business day of receipt if sent by facsimile transmission. Membersrenews automatically by continuing the payment of the monthly membership should allow three (3) to four (4) weeks for their refund. Members maydues. There is no renewal fee. In addition to paying monthly, the membership cancel their membership at any time after the first thirty (30) days, provideddues can be paid quarterly, semi-annually, or annually. If the member wishes American Workers Insurance Services is given a written notice of cancellation.to change their billing cycle, they should contact American Workers Insurance Membership package and cards must be returned upon cancellation. It mayServices at 1.866.365.5829. American Workers Insurance Services members take up to fourteen (14) to thirty (30) days after receiving a valid cancellationmay cancel their membership in writing without giving a reason during the request for collection of dues to stop.first thirty (30) days from the date of the postmark on the member fulfillment liMiteD aSSociation groUP inSUrance BeneFitS DiScloSUreS* Dental HMo: Deltacare® USa product offered as an association group ** $50 Physician Office Visit Reimbursement: Association group insurance benefit providedinsurance benefit. through an insurance policy (AH 24230-003) issued and underwritten by United States Fire Insurance Company.in california, Delta Dental® USa is underwritten and provided by Delta Dental ofcalifornia; 12898 towne center Drive, cerritos, ca 90703-8546. † $5K Accidental Injury and $10K Accidental Death & Dismemberment: Association group insurance benefits provided through a blanket special risk insurance policy (GA 26932-003)in Florida, Delta Dental® USa is underwritten and provided by Delta Dental issued and underwritten by United States Fire Insurance Company.insurance company; 1130 Sanctuary Parkway, Suite 600, alpharetta, ga 30009. § Emergency Travel Assistance: Association group insurance benefit provided through an Agreement with the Lifeguard Emergency Travel Corporation and a group insurance policy (RNMWC1003634) issued and underwritten by Lloyd’s of London. 10878 Westheimer Rd., Suite # 191, Houston, TX 77042 • Phone: 1.866.365.5829 • Fax: 1.866.837.4556

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