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 #:

Please check one or both of the following:

Plan(s) Applying For:     

        State 100 Dental             Yes        No

        Stand Alone Vision          Yes        No

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 Vision Association Fee:           +

                   Total Monthly:                = 

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: 

I hereby apply for dental and/or vision insurance through American Life Insurance Corp.

Date Signed:-- mm/dd/yy    

Insured Signature: 

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

Insured Signature:

Agent Name (if applicable):

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 Central Billing Service 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.