Please provide the following contact information:

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

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

Social Security Number 

Plan Applying For:     Economy Plan   Value Plan     Standard Plan  State 100

                        Deductible Selected   $50        $100

I Apply For:

Single Only
Insured &  Spouse
Insured & Child(ren)
Family

DO YOU HAVE ELIGIBLE DEPENDENTS (INCLUDING SPOUSE)?

Yes No

Spouse:     Relation:

Sex:      Male   Female                                   Birthdate: -- mm/dd/yy

Child(ren)'sName                 Relation      Sex     Birthdate

        M F -- mm/dd/yy

        M F -- mm/dd/yy

        M F -- mm/dd/yy

        M F -- mm/dd/yy

        M F -- mm/dd/yy

        M F -- mm/dd/yy

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.

Monthly Dental Premium:                        +

Monthly CARE Association Fee:                              +

                   Total Monthly:                    

PAYMENT OPTIONS (Choose One):          

Visa - Monthly
MasterCard - Monthly
 

Account #:             Expiration Date: -- mm/yy

Name as it appears on the card:
 

 I hereby apply for dental insurance through American Life Insurance Corp.

Agent Name (if applicable):

Date Signed:-- mm/dd/yy    

Insured Signature: 

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

Insured Signature:

By completing & submitting  this internet form you are applying for Dental/Vision coverage with Ameritas Life Insurance Company and 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.