Optima Care Deluxe

884 views

Published on

www.dmejia.awiscard.com

Our mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE association
group insurance, backed by the best customer service in the industry. That is why each of our plans has
been carefully created with select services and group benefi ts to offer you an exceptional healthcare value at a reasonable cost.

  • Be the first to comment

  • Be the first to like this

Optima Care Deluxe

  1. 1. an affordable solutionto match yourhealthcare needs CARE CHOICE
  2. 2. Care Choice, providing youwith affordable quality healthcareOur mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE associationgroup insurance, backed by the best customer service in the industry. That is why each of our plans has beencarefully created with select services and group benefits to offer you an exceptional healthcare value at areasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with CARE CHOICE: HOSPITAL PATIENT ADVOCACY  WORLDWIDE $10,000  WORLDWIDE EMERGENCY We work hard to lower your ACCIDENTAL INJURY TRAVEL ASSISTANCE hospital bills! You will be protected from virtually 100% coverage for worldwide ANY injury! air ambulance needs up ROADSIDE ASSISTANCE to $100,000! Keep your mind at ease and your car on the road!  WORLDWIDE $10,000 ACCIDENTAL DEATH & DISMEMBERMENT Protect your family from PET CARE unexpected expenses! Protect that “other” family member, YOUR PET!  $15,000 TERM LIFE / $15,000 ACCIDENTAL LEGAL SERVICES DEATH & DISMEMBERMENT Legal advice at your fingertips! Lessen the burden on your loved ones! $50 DOCTOR OFFICE VISIT REIMBURSEMENT Don’t use emergency rooms for primary care! Visit your Physician UP TO 5 times per family member per year. AWIS030_CARECHOICE_PITCHBROCHURE_ENGLISH REV:01.11.2011
  3. 3. SPONSOR & ENROLLER INFORMATION FOR OFFICE USE ONLYSponsor Name: Daniel Mejia 2 3 4 5 6 7IMA/MSA #: 43848 10878 Westheimer Rd., Suite # 191, Houston, TX 77042 Phone: 1.866.365.5829 Fax: 1.866.837.4556 Date:Enroller Name: Daniel Mejia MEMBER APPLICATIONIMA/MSA #: 43848 CARE CHOICE PLAN SERVICESFees and Dues: • Hospital Patient Advocacy • $50 Physician Of ce • $15K Term Life Insurance/ • Roadside Assistance Visit Reimbursement * $15K Accidental Death • Monthly Dues: $99.95 • $10K Accidental Injury & Dismemberment ‡ • Pet Care • One-Time Application Fee: $100 • $10K Accidental Death • Emergency§Travel • Legal Services Assistance & Dismemberment † 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 #: Bene ciary: MEMBERS 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: $ 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 designated attorney-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 membership recurringdues. I understand I am eligible for a refund of my membership dues if I cancel in writing by fax or mail within 30 days from postmark on my membership packetplus ve (5) days. 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.) AWIS030_CARECHOICE_APP REV:03.10.2011
  4. 4. AGREEMENT OF TERMS & CONDITIONS (PLEASE PRINT CLEARLY)I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Care Choice member. I further understand that by joining theCare Choice program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPP association andat no additional cost to me, I am entitled to limited association group insurance bene ts after a waiting period; for speci c bene t waiting periods, call MemberServices at 1.866.365.5829. These limited association group insurance bene ts are not comprehensive health insurance.I understand that I have purchased a membership in AWIS from ,IMA/MSA # .I have read and understand the cancellation policy and disclosures set forth below.X Date:Signature PROGRAM DISCLOSURESThe program‘s services and group bene ts are marketed by American Workers date of the postmark on the member ful llment package, plus ve (5) days,Insurance Services (AWIS), a licensed insurance agency. Not available in AK, and will receive a refund of membership dues paid. The one-time enrollmentCO, CT, FL, GA, GU, KS, MA, MD, ME, MN, MT, ND, NH, NJ, NY, OR, PR, SD, VA, VI, fee is held as a non-refundable processing fee ** . The cancellation effectiveVT, and WA. date shall be the date of the postmark if sent by mail and the business day of receipt if sent by facsimile transmission. Members should allow three (3) to fourCancellation Policy (4) weeks for their refund. Members may cancel their membership at any time after the rst thirty (30) ¶ days, provided American Workers Insurance ServicesAmerican Workers Insurance Services membership renews automatically by is given a written notice of cancellation. Membership package and cards mustcontinuing the payment of the monthly membership dues. There is no renewal be returned upon cancellation. It may take up to fourteen (14) to thirty (30) daysfee. In addition to paying monthly, the membership dues can be paid quarterly, after receiving a valid cancellation request for collection of dues to stop.semi-annually, or annually. If the member wishes to change their billing cycle,they should contact American Workers Insurance Services at 1.866.365.5829. ¶ Forty- ve (45) days in California.American Workers Insurance Services members may cancel their membership ** Fully refundable in Oklahoma and Tennessee. $30 of the enrollment fee will be non-refundable inin writing without giving a reason during the rst thirty (30) ¶ days from the CA, IL, IN, LA, SC, and TX. LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES* $50 Physician Of ce Visit Reimbursement: Association group insurance bene t provided ‡ $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group through an insurance policy (AH 24230-003) issued and underwritten by United States Fire insurance bene ts provided through an insurance policy (GL-855025) issued and underwritten Insurance Company. by Hartford Life and Accident Insurance Company.† $10K Accidental Injury and $10K Accidental Death & Dismemberment: Association group § Emergency Travel Assistance: Association group insurance bene t provided through an insurance bene ts provided through a blanket special risk insurance policy (GA 26932-003) Agreement with the Lifeguard Emergency Travel Corporation and a group insurance policy issued and underwritten by United States Fire Insurance Company. (HTP 05209) issued and underwritten by Virginia Surety Company, Inc. Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042

×