Please provide the following information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone

 

Social Security Number     

Date of Birth	-- mm/dd/yy
Gender	Male Female

Date of Hire:   

          Employer Name    

          Email Address    

I Choose to Enroll in the Limited Medical Program

Yes No

Plan Enrolling In:  

Freedom Plan     

Liberty Plan

I wish to enroll:

Member Only
Member Plus Spouse
Member Plus Child(ren)

Member Plus Family (Member, Spouse and Child(ren))

 

 

List first names of family members to be enrolled in TransChoice Program and complete full information in area designated below:   

Primary Beneficiary (Last, First, M.I.)          

Primary Beneficiary Relationship          

Contingent Beneficiary (Last, First, M.I.)         

Contingent Beneficiary Relationship          

I Choose to Enroll in the Dental Program (click here for more information)

Yes No

 

Plan Enrolling In:  

Value Plan     

Standard Plan

Royal Plan

I wish to enroll (Ameritas Dental):

Member Only
Member Plus Spouse
Member Plus Child(ren)

Member Plus Family (Member, Spouse and Child(ren))

 

List first names of family members to be enrolled in Ameritas Dental Program and complete full information in area designated below:   

I Choose to Enroll in the Eye Care Program (click here for more information)

Yes No

I wish to enroll (Ameritas Eye Care):

Member Only
Member Plus 1 (child or spouse)
Member Plus 2 or more

 

List first names of family members to be enrolled in Ameritas Eye Care Program and complete full information in area designated below:   

DO YOU HAVE ELIGIBLE DEPENDENTS (INCLUDING SPOUSE)?

Yes No

Spouse:     Relation:

Date of Marriage    -- mm/dd/yy

Gender:      Male   Female                  Spouse Birthdate: -- mm/dd/yy

Child(ren)'s Name           Relation  Gender  Birthdate                  Full Time Student

        M F -- mm/dd/yy    Yes No

        M F -- mm/dd/yy    Yes No

        M F -- mm/dd/yy     Yes No

        M F -- mm/dd/yy   Yes No

        M F -- mm/dd/yy   Yes No

        M F -- mm/dd/yy   Yes No

Any Additional Children?

Yes No

If the address of any child is different than the member's address, please show that child's name and address below:

If requesting coverage for dependent child other than a son or daughter, please forward legal papers.

Requested Effective Date: -- mm/dd/yy

**This does not guaranteed a specific effective date.  Your final effective date will be determined by when a completed application is received and a full month's premium has been collected.

Total Monthly Premium:

Monthly TransChoice Premium:                         

Click here to view TransChoice plans and premiums

(The amount that is shown on the benefits chart includes the TransChoice Premium, and Fees (including the $1 CARE Membership Fee))

Monthly Dental Premium:                                         + 

Click here to view Dental plans and premiums

(If you are not electing the TransChoice Program please add $1 to the Dental Premium for your CARE Membership Fee)

Monthly Eye Care Premium:                                    + 

Click here to view Eye Care plans and premiums

(If you are not electing the TransChoice Program please add $1 to the Dental Premium for your CARE Membership Fee)

Total Monthly Premium                                   =

PAYMENT OPTIONS (Choose One):       

*There is a 4% service fee for this option   

Visa - Monthly
MasterCard - Monthly

 

Account # :             -- (####-####-####-####)     Expiration Date:    -- (mm/yy)

Name as it appears on the card:           
 

When such insurance becomes effective, I agree to submit payment toward the cost of such insurance.

Insured Signature:    

 Please type your name the second time below for the confirmation of your signature.

Insured Signature:            

Date Signed:   -- mm/dd/yy    

Agent Name (if applicable):

By completing & submitting  this internet form you are enrolling in programs within the CARE Benefits Program.   You are also joining the CARE Association at a monthly cost of $1.  Your credit card will be charged for the appropriate monthly premium.

Cancellations are requested in writing, mailed to Greater Insurance Service Corp. at 414 Atlas Ave, Madison, WI  5714-3165 OR faxed to( 608) 221-0868.   Cancellation request must include:  your name (please print), your policy number, requested cancellation date,  and signature.  Cancellation date will be the later of your requested date or the first of the month after written notice is received.