1. Dental HMO Select
Dental Care
SolutionS
06597/CA-FL

2. Dental HMo Select
Our mission has always been to provide our members with a cost-effective and simple-to-use dental care program, backed by the
best customer service in the industry. That is why each of our plans has been carefully created with select services and group
benefits to offer you an exceptional dental care value at an affordable cost.
Sign-up today and enjoy the dental care solution you have been seeking with Dental HMO Select:
DENTAL HMO
Dental insurance coverage for you and
your loved ones with no deductible,
no annual or lifetime dollar
maximum. Receive simple-to-use,
quality dental services at affordable
out-of-pocket cost –– you no longer
have to grit your teeth at outrageous
dental fees!
Hospital patient advocacy
We work hard to lower your hospital bills!
leGal seRvices
Legal advice at your fingertips!
pet caRe
Protect that “other” family member, Your Pet!
06597/CA-FL AWIS048_DenTALHMOSeLeCT_CAFL | ReV:7.20.2011

3. SPonSor & enroller inForMation For oFFice USe only
2 3 4 5 6 7
Sponsor Name: _____________________
Daniel Mejia
43848
IMA/MSA #: ________________________ Date: ________________________________
10878 Westheimer Rd., Suite # 191, Houston, TX 77042
Daniel Mejia
Enroller Name: ______________________ Phone: 1.866.365.5829 • Fax: 1.866.837.4556 Dental office #: _______________________
43848
IMA/MSA #: ________________________ MeMBer aPPlication Dental office name: ___________________
Dental HMo Select Dental office Phone: ___________________
Plan ServiceS
FeeS anD DUeS:
• Dental HMO* • Legal Services
• Individual Monthly Dues: $39.95
• Hospital Patient Advocacy • Pet Care
• Family Monthly Dues: $79.90
• One-Time Application Fee: $60.00
MeMBer inForMation (Please Print Clearly)
Last Name: ___________________________ First Name: _______________________________ M.I.: _________________ D.O.B:________________
Mailing Address: _____________________________________________________________________________ Apt #: ________________________
City: _______________________________________________________________ State: ________________________Zip: ___________________
Gender: ____________________________________________________ Language: _____________________________________________________
E-mail: ____________________________________________________ Home Phone #: _________________________________________________
Cell Phone #: ________________________________________________ Work Phone #: __________________________________________________
Fax #: _____________________________________________________ Beneficiary: ____________________________________________________
MeMBer’S FaMily inForMation (Please Print Clearly)
Spouse’s First Name: ______________________________ Last Name:__________________________________________ D.O.B: _________________
Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________
Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________
Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________
Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________
Dependent’s First Name: ___________________________ Last Name:_________________________ D.O.B: ___________ Relationship:_____________
(For additional dependents, add additional sheets)
Billing inForMation (Please seleCt only one method oF Payment)
one-time application Fee: $ _______________Monthly Dues: $ ______________ optional Service: $_______________ total: $ _______________
Bank Draft or Debit: (check only one) Checking Savings
Name of Account Holder: ____________________________________________ Bank Name: _______________________________________________
Bank Transit #:____________________________________________________ Bank Account #: ____________________________________________
credit card: (check only one) VISA American Express Discover MasterCard
Name of Account Holder: _____________________________________________________________________________________________________
Account #: ________________________________________________________ Expiration Date: _______________________ CVV2 #: _____________
(The CVV2 # is the last 3 digits next to the signature line on the back of your credit card; or the 4 digits after your account # for American Express)
I have read the terms, conditions, and disclosures on the back of this application and authorize American Workers Insurance Services or its designated
attorney-in-fact to electronically draft my account or bill my credit card indicated on this application for my one-time initial application fee and my membership
recurring dues.
Check this box if you are paying for this membership and are not the member.
X________________________________________________________________________________________ Date: _________________________
Signature of the Depositor or credit card Holder (must be signed by employer if employer is paying the membership dues.)
06597/CA-FL AWIS048_DenTALHMOSeLeCT_CAFL | ReV:07.20.2011

4. agreeMent oF terMS & conDitionS (PleaSe Print clearly)
I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Dental HMO Select member. I further understand that by joining
the Dental HMO Select program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPP
association and at no additional cost to me, I am entitled to limited association group insurance benefits after a waiting period; for specific benefit waiting periods,
call Member Services at 1.866.365.5829. These limited association group insurance benefits are not comprehensive health insurance.
Daniel Mejia 43848
I understand that I have purchased a membership in AWIS from _________________________________ , IMA/MSA # ____________________________ .
I have read and understand the cancellation policy and disclosures set forth below.
X ________________________________________________________________________________________ Date: _________________________
Signature
PrograM DiScloSUreS
The program‘s services and group benefits are marketed by American Workers package, plus five (5) days, and will receive a refund of membership dues paid.
Insurance Services (AWIS), a licensed insurance agency. The one-time enrollment fee is held as a non-refundable processing fee. The
cancellation effective date shall be the date of the postmark if sent by mail
cancellation Policy: American Workers Insurance Services membership and the business day of receipt if sent by facsimile transmission. Members
renews automatically by continuing the payment of the monthly membership should allow three (3) to four (4) weeks for their refund. Members may
dues. There is no renewal fee. In addition to paying monthly, the membership cancel their membership at any time after the first thirty (30) days, provided
dues can be paid quarterly, semi-annually, or annually. If the member wishes American Workers Insurance Services is given a written notice of cancellation.
to change their billing cycle, they should contact American Workers Insurance Membership package and cards must be returned upon cancellation. It may
Services at 1.866.365.5829. American Workers Insurance Services members take up to fourteen (14) to thirty (30) days after receiving a valid cancellation
may cancel their membership in writing without giving a reason during the request for collection of dues to stop.
first thirty (30) days from the date of the postmark on the member fulfillment
liMiteD aSSociation groUP inSUrance BeneFitS DiScloSUreS
* Dental HMo: Deltacare® USa product offered as an association group in Florida, Delta Dental® USa is underwritten and provided by Delta Dental
insurance benefit. insurance company; 1130 Sanctuary Parkway, Suite 600, alpharetta, ga 30009.
in california, Delta Dental® USa is underwritten and provided by Delta Dental of
california; 12898 towne center Drive, cerritos, ca 90703-8546.
10878 Westheimer Rd., Suite # 191, Houston, TX 77042 • Phone: 1.866.365.5829 • Fax: 1.866.837.4556