Platinum Select TL App & Brochure

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Platinum Select TL App & Brochure

  1. 1. an affordable solutionto match yourhealthcare needs PLATINUM SELECT TL
  2. 2. Platinum Select TL, 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 hasbeen carefully created with select services and group benefits to offer you an exceptional healthcarevalue at a reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for withPLATINUM SELECT TL: HOSPITAL PATIENT ADVOCACY  WORLDWIDE $5,000  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! AWIS032_PLATINUMSELECTTL_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 PLATINUM SELECT TL PLAN SERVICESFees and Dues: •   Hospital Patient Advocacy •   $10K Accidental Death •   Emergency‡Travel •   Roadside Assistance & Dismemberment * Assistance •  Individual Monthly Dues: $69.95 •   Pet Care •   $15K Term Life Insurance/ •  Family Monthly Dues: $79.95 $15K Accidental Death •   Legal Services & Dismemberment † •  One-Time Application Fee: $100 •   $5K Accidental Injury * 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: 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:(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 five (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.) AWIS032_PlAtInumSelecttl_APP Rev:08.23.2011
  4. 4. AGREEMENT OF TERMS & CONDITIONS (PLEASE PRINT CLEARLY)I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Platinum Select TL member. I further understand that by joiningthe Platinum Select TL program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPPassociation and at no additional cost to me, I am entitled to limited association group insurance benefits after a waiting period; for specific benefit waiting periods,call Member Services at 1.866.365.5829. These limited association group insurance benefits are not comprehensive health insurance.I understand that I have purchased a membership in AWIS from Daniel Mejia ,IMA/MSA # 43848 .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 receive a refund of membership dues paid. The one-time enrollment fee is heldInsurance Services (AWIS), a licensed insurance agency. Not available in AK, CO, as a non-refundable processing fee ¶. The cancellation effective date shall beCT, GA, GU, MA, MD, ME, MN, MT, ND, NE, NY, OK, PR, SD, VI, and VT. 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 four (4) weeksCancellation Policy for their refund. Members may cancel their membership at any time after the first thirty (30)§ days, provided American Workers Insurance Services is givenAmerican Workers Insurance Services membership renews automatically by a written notice of cancellation. Membership package and cards must becontinuing the payment of the monthly membership dues. There is no renewal 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-five (45) days in California.American Workers Insurance Services members may cancel their membership ¶ Fully refundable in Tennessee. $30 of the enrollment fee will be non-refundable in CA, IL, IN, LA,in writing without giving a reason during the first thirty (30)§ days from the date SC, and TX.of the postmark on the member fulfillment package, plus five (5) days, and will LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES* $5K Accidental Injury and $10K Accidental Death & Dismemberment: Association group ‡ Emergency Travel Assistance: Association group insurance benefit provided through an insurance benefits 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. (RNMWC1003634) issued and underwritten by Lloyds of London.† $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group insurance benefits provided through an insurance policy (67432) issued and underwritten by ReliaStar Life Insurance Company. Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042

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