Dental HMO Select

Dental CareSolutionS

06597/CA-FL

Dental HMo SelectOur mission has always been to provide our members with a cost-effective and simple-to-use dental care program, 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 benefits to offer you an exceptional dental care value at an affordable cost.

Sign-up today and enjoy the dental care solution you have been seeking with Dental HMO Select:

Hospital patient advocacyWe work hard to lower your hospital bills!

leGal seRvices Legal advice at your fingertips!

pet caReProtect that “other” family member, Your Pet!

AWIS048_DenTALHMOSeLeCT_CAFL | ReV:7.20.2011

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!

06597/CA-FL

Plan ServiceS

10878 Westheimer Rd., Suite # 191, Houston, TX 77042 Phone: 1.866.365.5829 • Fax: 1.866.837.4556

AWIS048_DenTALHMOSeLeCT_CAFL | ReV:07.20.2011

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 Savings

Name of Account Holder: ____________________________________________ Bank Name: _______________________________________________

Bank Transit #: ____________________________________________________ Bank Account #: ____________________________________________

credit card: (check only one) VISA American Express Discover MasterCard

Name 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 recurring 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.)

SPonSor & enroller inForMation Sponsor Name: _____________________

IMA/MSA #: ________________________

Enroller Name: ______________________

IMA/MSA #: ________________________

Date: ________________________________

Dental office #: _______________________

Dental office name: ___________________

Dental office Phone: ___________________

For oFFice USe only

2 3 4 5 6 7

MeMBer aPPlicationDental HMo Select

•   Individual Monthly Dues: $39.95•   Family Monthly Dues: $79.90•   One-Time Application Fee: $60.00

FeeS anD DUeS:•   Dental HMO*•   Hospital Patient Advocacy

06597/CA-FL

•   Legal Services•   Pet Care

10878 Westheimer Rd., Suite # 191, Houston, TX 77042 • Phone: 1.866.365.5829 • Fax: 1.866.837.4556

agreeMent oF terMS & conDitionS (PleaSe Print clearly)

I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Dental HMO Select member. I further understand that by joining the Dental HMO Select program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPP association 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 _________________________________ , IMA/MSA # ____________________________ .

I have read and understand the cancellation policy and disclosures set forth below.

X ________________________________________________________________________________________ Date: _________________________ Signature

PrograM DiScloSUreS

The program‘s services and group benefits are marketed by American Workers Insurance Services (AWIS), a licensed insurance agency.

cancellation Policy: American Workers Insurance Services membership renews automatically by continuing the payment of the monthly membership dues. There is no renewal fee. In addition to paying monthly, the membership dues can be paid quarterly, 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. American Workers Insurance Services members may cancel their membership in writing without giving a reason during the first thirty (30) days from the date of the postmark on the member fulfillment

package, plus five (5) days, and will receive a refund of membership dues paid. 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 mail and the business day of receipt if sent by facsimile transmission. Members should allow three (3) to four (4) weeks for their refund. Members may cancel their membership at any time after the first thirty (30) days, provided American Workers Insurance Services is given a written notice of cancellation. Membership package and cards must be returned upon cancellation. It may take up to fourteen (14) to thirty (30) days after receiving a valid cancellation request for collection of dues to stop.

liMiteD aSSociation groUP inSUrance BeneFitS DiScloSUreS

* Dental HMo: Deltacare® USa product offered as an association group insurance benefit.

in california, Delta Dental® USa is underwritten and provided by Delta Dental of california; 12898 towne center Drive, cerritos, ca 90703-8546.

in Florida, Delta Dental® USa is underwritten and provided by Delta Dental insurance company; 1130 Sanctuary Parkway, Suite 600, alpharetta, ga 30009.