Please provide the following information:

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

 

Email Address 

 

Social Security Number     

 

Date of Hire:   

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

I Choose to Enroll in the TransChoice Plus Limited Medical Indemnity Program

Yes No

Plan Enrolling In:  

First Class Plan

Priority Plan

Express Plan

I wish to enroll (TransChoice Plus):

Member Only
Member Plus Spouse
Member Plus Child(ren)

Member Plus Family (Member, Spouse and Child(ren))

 

List first names of family members to be enrolled in TransChoice Plus Program and complete full information in area designated below:   

Primary Beneficiary (Last, First, M.I.)          

Primary Beneficiary Relationship          

Contingent Beneficiary (Last, First, M.I.)         

Contingent Beneficiary Relationship          

I Choose to Enroll in the Ameritas Dental/Eye Care Plan

Yes No

Dental/Eye Care Plan Enrolling In:  

Value Plan

Standard Plan

Royal Plan

100/70/50 Plan

 

 

I wish to enroll (Ameritas Dental/Eye Care):

Member Only
Member Plus One (Spouse or Child)
Member Plus 2 or more

 

List first names of family members to be enrolled in Dental/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:

Requested Effective Date: -- mm/dd/yy

**This does not guaranteed a specific effective date.  Your final effective date will be determined by when a completed application is received and a full month's premium has been collected.

Total Monthly Premium:

Monthly TransChoice Plus Premium:    

                                                                                            +

Monthly Dental/Eye Care Premium:         

                                                                                            =

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.

Insured Signature:   

Date:          

 Please type your name the second time below along with the last four digits of your SSN for the confirmation of your signature

Insured Signature:             Last Four Digits of SSN     

By completing & submitting  this internet form you are applying for the NRLCA TransChoice Benefit Program and/or the Ameritas Dental and Eye Care Benefit Program. 

Cancellations are requested in writing, mailed to Greater Insurance Service Corp. at 414 Atlas Ave, Madison, WI  53714-3165 OR faxed to( 608) 221-0484.   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.