Entry Date
ROSTER
ONLINE
BILLING
ABN


Underwritten By:

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Select the FIRST 3 DIGITS of the Zip Code for which you reside. IMPORTANT: MUST MATCH THE FIRST 3 DIGITS OF ZIP CODE OF YOUR ADDRESS WHEN APPLYING FOR COVERAGE. Plan may not be available in all areas.

Indicate Coverage Desired - Part II -

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Total Monthly Cost includes $2.00/monthly ABN association dues required to enroll in Dental and/or Vision plan. Payments may be made via Monthly Auto Pay (ACH) or Direct Annual Payment. If Direct Annual Payment Mode is selected, you will be required to make your initial payment by credit card. A one-time $20.00 non-refundable processing fee is also due at the time of enrollment for all payment types. For employees of businesses with 5 or more participants, contact administrator for firm list billing options. Premiums are guaranteed not to change before 12/31/22 and are subject to change thereafter.

Click "Next" to continue enrollment.

Indicate Coverage Desired - Part II

Not sure which plan to select? Compare options here »

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Total Monthly Cost includes $2.00/monthly ABN association dues required to enroll in Dental and/or Vision plan. Payments may be made via Monthly Auto Pay (ACH) or Direct Annual Payment. If Direct Annual Payment Mode is selected, you will be required to make your initial payment by credit card. A one-time $20.00 non-refundable processing fee is also due at the time of enrollment for all payment types. For employees of businesses with 5 or more participants, contact administrator for firm list billing options. Premiums are guaranteed not to change before 12/31/22 and are subject to change thereafter.

Click "Next" to continue enrollment.

Indicate Coverage Desired - Part II - FLBAR

FLBAR - MetLife PPO Plan Type - Area 1*
FLBAR - MetLife PPO Plan Type - Area 2-1*
FLBAR - MetLife PPO Plan Type - Area 2*
FLBAR - MetLife PPO Plan Type - Area 2-3*
FLBAR - MetLife PPO Plan Type - Area 3-1*
FLBAR - MetLife PPO Plan Type - Area 3-2*
required to enroll in this plan.
FLBAR - MetLife PPO Plan Type - Area 3*
FLBAR - MetLife PPO Plan Type - Area 4*
FLBAR - MetLife PPO Plan Type - Area 5*
FLBAR - MetLife PPO Plan Type - Area 6*

Not sure which plan to select? Compare options here »

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Total Monthly Cost includes $2.00/monthly ABN association dues required to enroll in Dental and/or Vision plan. Payments may be made via Monthly Auto Pay (ACH) or Direct Annual Payment. If Direct Annual Payment Mode is selected, you will be required to make your initial payment by credit card. A one-time $20.00 non-refundable processing fee is also due at the time of enrollment for all payment types. For employees of businesses with 5 or more participants, contact administrator for firm list billing options. Premiums are guaranteed not to change before 12/31/22 and are subject to change thereafter.

Click "Next" to continue enrollment.

Would you like to add these enhanced benefits?

MDLIVE - Telehealth*
Covers members and all eligible dependent family members.


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Total Monthly Cost includes $2.00/monthly ABN association dues required to enroll in Dental and/or Vision plan. Payments may be made via Monthly Auto Pay (ACH) or Direct Annual Payment. If Direct Annual Payment Mode is selected, you will be required to make your initial payment by credit card. A one-time $20.00 non-refundable processing fee is also due at the time of enrollment for all payment types. For employees of businesses with 5 or more participants, contact administrator for firm list billing options. Premiums are guaranteed not to change before 12/31/22 and are subject to change thereafter.

Web Enrollment & Electronic Signature Agreement

Consumer Disclosure Regarding Conducting business electronically, Receiving Electronic Notices and Disclosures, and Signing Documents Electronically

Please read the following information, by proceeding forward and signing this document you are agreeing that you have reviewed the following consumer disclosure information and consent to transact business using electronic communications, to receive notices and disclosures electronically, and to utilize electronic signatures in lieu of using paper documents. This electronic signature service is provided on behalf of Member Benefits "sending party", administrator of the ABN Dental Program, whom are sending electronic documents, notices, disclosures or requesting electronic signatures to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time as described below.


Paper Copies

You are not required to receive notices or disclosures or sign documents electronically and may request paper copies of documents or disclosures if you prefer to do so. You also have the ability to download and print any open or signed documents sent to you through the electronic signature system. Member Benefits may also email you a PDF copy of all agreements you sign using the service. If you wish to receive paper copies in lieu of electronic documents you may close this web browser and request paper copies from Member Benefits by following the procedures outlined below.

Use of the Service requires a standards-compliant web-browser which supports the HTTPS protocol, HTML, and cookies. Viewing PDF documents requires additional software such as Adobe Reader or similar.


Withdrawal of Consent

You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify Member Benefits that you wish to withdraw consent and to provide your future documents, notices, and disclosures in paper format. After withdrawing consent if at any point in the future you proceed forward and utilize the electronic signature system you are once again consenting to receive notices, disclosure, or documents electronically. You may withdraw consent to receive electronic notices and disclosures and optionally electronically signatures by following the procedures described below.


Scope of Consent

You agree to receive electronic notices, disclosures, and electronic signature documents with all related and identified documents and disclosures provided over the course of your relationship with Member Benefits. You may at any point withdraw your consent by following the procedures described below. You agree to receive communications from Member Benefits regarding coverage, program availability, and other important updates via email. Your privacy is extremely important to us; we do not sell personally identifiable information to outside parties, and we follow strict security standards. You have the ability to change email delivery preferences and/or opt out at any time. For a full summary of our privacy practices, please visit the Privacy Policy page.


Requesting paper copies only, withdrawing consent, and updating contact information

You will have the ability to download and print any documents you complete through the electronic signature system. To request only paper copies of documents, withdraw consent to conduct business electronically and receive documents, notices, or disclosures electronically or sign documents electronically, please contact Member Benefits by telephone (800) 282-8626, or by sending an email to (support@memberbenefits.com) with the following subjects:

“Requesting Paper Copies” Please provide your name, email, telephone number, postal address and document title.

“Withdraw Consent” Please provide your name, email, date, telephone number, postal address.

“Update Contact Information” Please provide your name, email, telephone number and postal address.

Primary Enrollee Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Name*
Mailing Address*

Primary Enrollee Identification

No Dashes
Gender*
Date of Birth*

Dependent Information

Please only list dependents to be covered. Spouses, domestic partners, and dependent children age 26 and under are eligible to be covered on your plan.

Spouse/Dom. Partner Name*
Spouse/Dom. Partner Date of Birth*
Spouse/Dom. Partner Gender*
Dependent Child 1 Name*
Dependent Child 1 Date of Birth*
Dependent Child 1 Gender*
Dependent Child 2 Name
Dependent Child 2 Date of Birth
Dependent Child 2 Gender
Dependent Child 3 Name
Dependent Child 3 Date of Birth
Dependent Child 3 Gender
Dependent Child 4 Name
Dependent Child 4 Date of Birth
Dependent Child 4 Gender

Payment Information

This online application utilizes an SSL Certificate to ensure secure transmission of your information.

Payment Option 1 - Monthly Auto Pay
If you elect to pay by Monthly Bank Draft (ACH), you do not need to send any premium, we will automatically draft your account on a monthly basis starting on your Coverage Effective Date. Your 1st monthly draft will include the one-time $20.00 processing fee*.


Payment Option 2 - Direct Annual Billing (Initial Annual Payment via Credit Card)

If you elect this method, you will need to make your initial payment via Credit Card for the premium required to pay your coverage through the end of the group plan year (December 31st) plus the one-time $20.00 processing fee*. Your card will not be charged thereafter and you will be invoiced on an annual basis for premiums due January 1st each group plan year. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).


*A $20.00 non-refundable processing fee is required for each enrollment regardless of payment type.. List bill options are available for businesses of 5 or more primary enrollees from the same business. Contact administrator for Firm list billing options.


Coverage Effective Date
Coverage is to be made effective on the 1st day of the month following your enrollment date and after receipt of your initial premium payment.
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Required payment to pay for coverage and assoc dues up through the end of the plan year (Dec 31st) + $20.00 one-time processing fee. November 1 and December 1 effective dates require pro-rata payment for the current plan year and payment for coverage up through the end of the following plan year (Dec 31st).
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IMPORTANT: DO NOT USE DEPOSIT TICKET NUMBERS as these numbers are often different than your checking ABA and Account number's. Routing and Account number must be from an authorized Checking account. An actual check is the best source to acquire the proper routing information.

Monthly Auto Pay Authorization*

IMPORTANT:

Monthly Auto Pay ACH Transactions from your bank account are performed by the plan administrator Member Benefits. Please make sure to recognize us on your bank statement as:


MEMBERBENEFITS48

One Time Credit Card Payment Authorization*

IMPORTANT:

Please note, premium billing for this plan is administered by the plan administrator Member Benefits. Please make sure to recognize us on your credit card statement as: 


MEMBERBENEFITS

Enrollment/Membership/Administration Agreement

Membership/Dental/Vision Enrollment Agreement*
Use your mouse or finger to draw your signature above
If an Employee, list your Employer's Member ID#
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Year End
Entry Month
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