Illinois Retired Teachers Association


Dental & Vision Enrollment Form

1

Tell Us About Yourself

Date of birth

Gender

2

Choose Your Coverage


Coverage Start Date

Coverage must start at the beginning of the month.


Dental Product

Member Only: $40.22

Member + One: $80.52

Member + Family: $102.39

Plan coverage >
Select An Option

Have you had dental coverage within the past 60 days?


Vision Product

Member Only: $11.94

Member + One: $20.94

Member + Family: $26.05

Details >
Select An Option

Number of Dependents

Your spouse and dependent children up to the month they turn age 26 are eligible for coverage. Disabled dependent children 26 and older may be covered indefinitely.

3

Billing Information


Authorization to honor drafts by the Association Member Benefits Advisors (AMBA).

NOTE: Bank drafts occur on the 2nd business day of each month.


Terms and Conditions

I understand and agree that I am enrolling as a member into the American Senior Benefits Association, which is a complimentary membership. I understand that I am submitting an application for dental or vision insurance marketed by Association Members Benefits Advisors (AMBA). Each application includes a one-time $20 enrollment fee that is assessed on the same day as my first initial premium (void where prohibited). I understand that if I have any further questions I can reach AMBA at 1-877-290-3165. Should I decide to terminate my coverage during the first thirty days I am entitled to a refund of my premiums. I will return any claims paid during that time to the insurer. Terminations must be submitted in writing. I understand that by completing this form and clicking the submit button I am requesting coverage for the endorsed plans marketed through Association Members Benefits Advisors (AMBA).


LIMITATIONS & EXCLUSIONS
Covered Expenses will not include and no benefits will be payable for expenses incurred:
  • for any treatment which is for cosmetic purposes, except as specifically listed in the Table of Dental Procedures.
  • to replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed partial denture within five years of the date of the last placement of these items. However, if a replacement is required because of an accidental bodily injury sustained while the plan member is covered under the dental expense benefit, it will be a Covered Expense.
  • for initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the plan member is covered under the dental expense benefit. The extraction of a third molar (wisdom tooth) will not qualify under the above. Any such dental prosthesis or prosthetic crown must include the replacement of the extracted tooth or teeth.
  • for any procedure begun before the plan member was covered under the dental expense benefit.
  • for any procedure begun after the member’s insurance under the dental expense benefit terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the member’s insurance under the dental expense benefit terminates.
  • to replace lost or stolen appliances.
  • for appliances, restorations, or procedures to:
  • alter vertical dimension;
  • restore or maintain occlusion;
  • splint or replace tooth structure lost because of abrasion or attrition
  • for any procedure which is not shown on the Table of Dental Procedures.
  • for orthodontic treatment (unless otherwise specified in this contract.)
  • for which the plan member is entitled to benefits under any workmen’s compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit.
  • for charges for which the plan member is not liable or which would not have been made had no insurance been in force.
  • for services which are not required for necessary care and treatment or are not within the generally accepted parameters of care.
  • because of war or any act of war, declared or not.

These dental insurance benefits, issued on Form Series 9000 Rev. 04-13, are underwritten by Ameritas Life Insurance Corp., a NE domiciled life insurance company with main offices located at 5900 O Street, Lincoln, NE 68521. Licensed in all states except NY, RI and NH. These products, and their features are subject to states availability and may vary by state. Certain exclusions and limitations may apply, for cost and complete details of coverage, please contact us or your agent. Ameritas Life Insurance Corp. (“Amer­itas”) provides the Dental coverage. Ameritas does not provide nor is it affiliated with any of the other programs provided as a part of this ASBA benefit package.