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

          Email Address    

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.

I Choose to Enroll in the Dental Program

Yes No

 

 

Plan Enrolling In:  

Economy Dental/Eye Care Plan     

Value Dental/Eye Care Plan

100/80/50 Dental Plan

I wish to enroll (Ameritas Dental Program):

Member Only
Member Plus 1 (Child or Spouse)
Member Plus 2 or more

 

 

I Choose to Enroll in the Stand Alone Eye Care Program

Yes No

I wish to enroll (Ameritas Eye Care Program):

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

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

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

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:

 Monthly Dental Premium:          Click here to view premiums 

 Monthly EyeCare Premium:     Click here to view premiums 

 Monthly Total Premium:             

PAYMENT OPTIONS (Choose One):     

*There is a 4% service fee for this option     

Visa - Monthly  *There is a 4% service fee for this option   
MasterCard - Monthly  *There is a 4% service fee for this option   
 

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:   

Date:          

 Please type your name the second time below along with the last four digits of your SSN for the confirmation of your signature

Insured Signature:             Last Four Digits of SSN     

By completing & submitting  this internet form you are applying for the WREA Dental and Eye Care Benefit Program.  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) 221-0484.   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.