AmeriPlan Health Plan Application Form

AmeriPlan Health™ Enrollment Application
Medical-Dental-Vision-Prescription-Chiropractic Plan

IF U HAVE ALREADY AMERIPLAN® BENEFITS PLEASE ENTER

INDEPENDENT BUSINESS

MEMBER #

OWNERS #

APPLICANT FIRST NAME

LAST NAME

SOCIAL SECURITY #

DATE OF BIRTH OF APPLICANT

STREET ADDRESS

APT.#

CITY

STATE

ZIPCODE

HOW LONG AT ADDRESS

OWN

RENT

OTHER

EXPLAIN OTHER

M.O. PAYMENT

PRESENT EMPLOYER

HOW LONG?
M/Y

RETIRED WHEN

FAMILY
MO.INCOME

# OF DEPEND

WORK TELEPHONE

MOTHER'S MAIDEN NAME:

HOME TELEPHONE

DRIVERS LICENSE #

STATE

MEMBER OF THE HOUSEHOLD

FIRST NAME

LAST NAME

DATE OF BIRTH

LIST ADDITIONAL HOUSEHOLD
MEMBERS ON SEPARATE PAGE

BY SIGNING THE DRAFTING AUTHORIZATION BELOW, I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THAT AMERIPLAN HEALTH™ PLAN IS NOT INSURANCE. AMERIPLAN HEALTH™ IS A DISCOUNT FEE-FOR-SERVICE PLAN AND I MUST PAY ANY CHARGES AT THE TIME SERVICES ARE RENDERED.

I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY:

BANK DRAFT: Draft on the

3rd or

18^th of the month.

By Submitting Your enclosed check, you are authorizing the ongoing draft until AmeriPlan® is notified of cancellation in writing.

SIGNATURE FOR BANK DRAFT

CREDIT CARD:

Visa

Master Card

Discover

American Express

Card#

Expiration Date

SIGNATURE FOR CREDIT CARD

A One time $30.00 Registration Fee is required with each application.

First Month Membership Fee
(Monthly Fee: $49.95 Single/$59.95 Family)

First Quarter Membership Fee
(Quarterly Fee: $149.85- Single/$179.85 Family)

First Year Membership Fee
(Annual Fee:$599.40 Single/$719.40 Family)

One-time Registration Fee
(Non Refundable)

30.00

TOTAL AMOUNT DUE

30 DAYS WRITTEN CANCELLATION NOTICE REQUIRED

MONTHLY OR QUARTERLY PAYMENTS MUST BE MADE BY ELECTRONIC BANK DRAFT OR BY CREDIT CARD.
INVOICING IS AVAILABLE FOR ANNUAL MEMBERSHIPS ONLY WITH FIRST YEAR PAID IN ADVANCE

I (We) the undersigned certify the membership application information is complete and accurate to the best of my (our) knowledge. If this application is accepted and charge card(s) is (are) issued, the undersigned Applicant(s) by signing, using or permitting another to use the MasterCard charge card(s) agree(s) that the applicants(s) will be bound by the terms and conditions of the Cardholder Agreement accompanying the charge card(s) and all amendments. The Cardholder Agreement is governed by Illinois law. I (we) give the above information for the purpose of obtaining and maintaining credit. I (we) authorize said Bank to obtain information concerning any statements made herein and authorize said Bank to check my (our) credit and employment history and to answer questions about credit experience with me (us). If I (we) ask, I (we) will be told whether or not consumer reports on me (us) were requested and the names of credit bureaus, with their addresses, that provided the reports. I (we) agree, jointly and separately, to pay the account(s) herein applied in for in full. Amalgamated Bank of Chicago is responsible for the issuing of the secured and unsecured revolving credit lines only and is NOT repsonsible for any representation made by any other party, or any programs, products or performance of the same. Variable Annual Percentage Rate (APR) for AmeriPlan® Standard Card is Prime Plus 8.74%. Minimum APR is 13.99% Rates (APR) are subject to change on the 15th day of each month. Your statement cycle rate is determined by the Prime Rate as published in the Wall Street Journal on the last day of the preceding month, plus 8.74%. The minimum APR for the AmeriPlan® Program Cards is 13.99% (Period Rate 1.166%).

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APPLICANT SIGNATURE		DATE

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APPLICANT SIGNATURE		DATE

CO APPLICANT SOCIAL SECURITY NUMBER

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, the USA Patriot Act requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What that means for you: When you open an account, we will ask for your name, physical address, date of birth, taxpayer identification number and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We will let you know if other information is required.

Complete and mail application to:

Ameriplan USA®, 5700 Democracy Drive, Plano, TX 75025
or you can fax to 469-229-4589