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

          Employer Name    

          Email Address    

I Choose to Enroll in the Dental & Eye Care Program

Yes No

 

 

Plan Enrolling In:  

Value Plan     

Standard Plan

Royal Plan

I wish to enroll:

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

 

 

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 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

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:

Total Monthly Premium:

Monthly Dental Premium:                                          

Click here to view Dental plans and premiums

Monthly Eye Care Premium:                                +  

Click here to view Eye Care premiums

CARE Membership Fee:                                           + 

Total Monthly Premium                                 =

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

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.

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 the WBA Care Dental & Eye Care 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 the GIS Benefit Center 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.