American Benefits Plan - Creative Benefit Design

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	PREMIUM PLAN
	Dental Care
	Pharmacy Discount Plan
	Lab & Imaging
	Nurse Hotline
	Chiropractic
	Vision Care
	Hearing Services
	Spa-Quality Skincare
	Alternative Medicine

	PREMIUM PLUS PLAN
	All 9 Premium Benefits,
	Plus Physician/Hospital

You may apply online with a credit card or download the application print and mail it in with your check, money order or credit card information.

Mail your application to:

Creative Benefit Design
P.O. Box 3025
Terre Haute, IN 47803

American Benefits Plan Online Application:

Please fill out form completely. Fields marked with * are Required

Name of Organization:

Date of Birth:
Please use (xx-xx-xxxx) format.

Sex

Number of Dependents

Full Name:

Address:

City

County

State

Zip Code:

Daytime Contact Telephone:
Please include area code.
Please use (xxx-xxx-xxxx) format.

Daytime Phone

Email:

Plan and Payment Information:

Type of Plan and Billing - Select 1 Plan Only.

1 plan covers your enitre houshold.

---- Premium Plan ----
Product	Order
Billed Monthly $9.95 + One Time Admin Fee $5.00
Billed Annually $119.40 + One Time Admin Fee $5.00
*---- Premium Plus Plan ----*
Product	Order
Billed Monthly $14.95 + One Time Admin Fee $5.00
Billed Annually $179.40 + One Time Admin Fee $5.00

ADDITIONAL TERMS AND CONDITIONS: I understand my credit card will be billed monthly or yearly, depending on selected plan, and that this agreement will remain in effect until Americare Benefits Plan has received a written notice from me that it should be cancelled. To ensure prompt cancellation of my Americare Benefits Plan program, this notice must be submitted at least 15 days but not less than 3 days, prior to my next scheduled payment date.

Signature

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Signature Required

By submitting this form, I agree to have Creative Benefit Design charge to my credit card the amount entered above and to the Terms and Conditions listed above.

We gladly accept
Accepted Cards

Fees:

Premium Plan
14.95 - Billed Monthly $9.95 + One Time Admin Fee $5.00
124.40 - Billed Annually $119.40 + One Time Admin Fee $5.00

Plan Includes
Dental Care
Pharmacy Discount Plan
Nurse Hotline (24/7)
Lab & Imaging
Chiropractic
Vision Care (Including Lasik)
Alternative Medicine
Hearing Services
Spa-Quality Skincare

Premium Plus Plan
19.95 - Billed Monthly $14.95 + One Time Admin Fee $5.00
184.40 - Billed Annually $179.40 + One Time Admin Fee $5.00

Plan Includes
All 9 Premium Plan Benefits, Plus
Physician/Hospital Visit

*Not Available in Washington, Kansas or Vermont*
This is not insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. For a full list of disclosures please Click Here. Discount Medical Plan Organization: New Benefits, Ltd. Attn: Compliance Department, PO Box 671309 Dallas, TX 75367-1309 \| 800-800-7616

Form number: 63037A-W

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