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Association Member Dental Enrollment Form

Number of People Enrolling

How many people will you be enrolling?

Cost of Coverage
$49.95 + $55.00 (One-time Enrollment Fee)

Your Information

Sex

(mm/dd/yyyy)

I do not have an email address.

Family Information

Qualifying  Age:   A Dependent Child is eligible for dental coverage to the age of
At this age the Dependent Child will need to have their own individual membership/dental coverage.

Choose your Dentist

Facility Choice for Policy Holder:

 

Comments

Terms & Commitment

Payment Information

Sales Agent
Dental Plan Type
Effective Date
Monthly Premium
Payments
Amount Drafting Today
Payment type
Choose Monthly Draft Date

       
   

(Name on card) First name
Last Name
Billing Address
City
State Zip Code
Account Type  
Bank Name
Routing Number
Account Number
Credit Card Type
Credit Card Number
Exp. Date
CCV
Comments

 

Payment Authorization

Total Amount of Payment $ Price includes 55.00 setup fee

I authorize my bank to debit my account as identified above to the terms stated here. This authorization shall remain in effect until the Service Provider and bank receive written notification from me of intent to terminate at such time and in such manner as to afford the Service Provider and bank reasonable opportunity to act (Minimum 30 days). I understand that if the total amount owed to the Service Provider is increased, I authorize this plan to continue as long as the payment amount remains unchanged until the amount owed the Service Provider is paid off, or unless the plan is terminated earlier by me as above. I understand any added amounts can be applied for with a new ACH Debit Authorization Form. All other changes such as payment amount, frequency, bank account number change, will require a new ACH Debit Payment Authorization Form to be filled out and submitted to Merchant 15 days prior to any change being implemented. I understand that this payment plan may be cancelled by the Service Provider or Merchant due to NSF (Non-sufficient Funds). I will be liable to pay an NSF fee of $25.00 (or the amount allowable by law), which may be automatically debited for each NSF. I represent and warrant that I am authorized to execute this payment authorization for the purpose of implementing this payment plan. I indemnify and hold the Service Provider, the bank, and Merchant harmless from damage, loss or claim resulting from all authorized actions hereunder.