AmeriPlan™ USA Enrollment Application
Dental-Vision-Prescription-Chiropractic Plan

Enrolling Broker #
Broker ID Number

First Name

MI

Last Name
First Name Last Name
Middle Initial

Date of Birth of Applicant

Male/Female

Residence or Work Telephone

Alternate Telephone

-

Date of Birth Month Date of Birth Day

-

Date of Birth Year Male Female
Phone Area Code

-

Phone prefix

-

phone number Alt Phone area code

-

Alt phone prefix

-

Alt Phone Number

Mailing Address

Apt. #
Street Address Apt Number

City

State

Zip

Applicant's Employer
Address City Address Zip Code Employer Name
Address State

LIST OF HOUSEHOLD MEMBERS

First Name

Last Name

Date of Birth


LIST

ADDITIONAL

HOUSEHOLD

MEMBERS ON

REVERSE

SIDE
First Member first name First Member last name
First DOB Month First DOB Day First DOB Year

A One-time $20.00 Registration Fee is
required with each application.

By submitting your enclosed check, you are authorizing the ongoing draft
Until AmeriPlanT is notified of cancellation in writing.

First Month Membership Fee                   $ __________
(Monthly Fee--$11.95 Single/ $19.95 Family)

X

First Quarter Membership Fee                  $ __________
(Quarterly Fee--$35.85 Single/ $59.85 Family)

SIGNATURE FOR BANK DRAFT

First Year Membership Fee                       $ __________
(Annual Fee--$143.40 Single/ $239.40 Family)

Expiration Date

Card #

X

SIGNATURE FOR CREDIT CARD

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.

Enclose your check for payment and a voided check if paying monthly or quarterly by bank draft--30-day written cancellation notice required.

AmeriPlan™
Attention: Application Processing
5700 Democracy Drive
Plano, TX 75024

Mail Completed Application to: