Online Application

 

 

NFU Dental/Vision Plan Membership Application

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    

 

   

 

Plan Applying For:     Economy Plan   Value Plan     Standard Plan        Consumer % Plan

 

I Apply For:

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

 

 

DO YOU HAVE ELIGIBLE DEPENDENTS (INCLUDING SPOUSE)?

Yes No

Spouse:     Relation:

Gender:      Male   Female                  Spouse Birthdate: -- mm/dd/yy

Child(ren)'s Name           Relation  Gender  Birthdate                  Full Time Student

        -- mm/dd/yy    Yes No

        -- mm/dd/yy    Yes No

        -- mm/dd/yy     Yes No

        -- mm/dd/yy   Yes No

        -- mm/dd/yy   Yes No

        -- 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:                            

 

 

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 Greater Insurance Service Corp. 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.