ABN MetLife Dental Enrollment

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.

Email*

Confirm Email *

Primary Enrollee Information

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

Applying As:

Name*

First Name

Initial (optional)

Last Name

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Primary Enrollee Identification

Social Security #*

No Dashes

Gender*

Male Female

Date of Birth*

Member Name

Occupation*

Employer Name (if employed)

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 Auto Pay / 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. The cost for this service is an additional .50/per month which will be added to your monthly amount drafted. 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.

Payment Method*

Monthly Draft Amount $

Initial Premium Payment Required $

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).

Processing Fee $

Monthly Auto Pay Fee $

Accountholder's Name*

Name of Bank or Financial Institution*

ABA Routing Number*

Confirm *

Account Number*

Confirm *

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*

I hereby authorize Member Benefits (MB) to initiate debit and credit entries to my Checking account and my Bank/Financial Institution to debit and/or credit the same account. I understand and agree to pay an additional .50 per month to utilize this service. MB will not be held responsible for a policy lapse or cancellation due to nonpayment if withdrawal is prepared and not honored for any reason and amount due is not paid within the payment Grace Period. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. Service fees, when applicable by law, may apply for ACH debit returns. MB and my Bank/Financial Institution may discontinue this service. This authority is to remain in full force and effective until MB has received written notice from me of its termination in such time and manner as to afford MB and my Bank/Financial Institution a reasonable opportunity to act on it.

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

Credit Card*

One Time Credit Card Payment Authorization*

I hereby authorize Member Benefits to make a one time debit to my credit card listed above. By agreeing, I give permission to immediately debit my account upon completion of my online enrollment. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to my account. I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the insurance coverage described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

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*

I hereby apply for group insurance, for which I am eligible or may become eligible. I understand that I am enrolling as a participant in a group plan. The plan provider, premium rates, and plan benefits may change. I have read and understand the conditions and plan limitations as described in the plan materials made available through this website. I understand that the dental plan I'm enrolling into is subject to waiting periods for certain types of services. I understand that my new enrollment will replace any existing coverage I may have in the Member Group Dental-Vision plans. I understand that the plan administrator, Member Benefits “MB”, may reject my enrollment submission if I do not meet all of the eligibility requirements for this plan and will notify me in the event that my submission has been rejected, otherwise my coverage is to be made effective on the 1st day of the month following my enrollment date and after receipt of my initial premium payment. MB reserves the right to decline or delay an enrollment if verification of eligibility and receipt of initial payment cannot be confirmed. I understand all premium payments, coverage changes, and cancellation requests must be submitted, in writing or through the appropriate web form, directly to the plan administrator, MB. Change or cancellation requests submitted directly to MetLife will not be honored. I understand and agree that I have made my plan election and selected my covered dependents for the plan year, up through December 31st. My elections are fixed up to the next annual open enrollment date (January 1st), after which time my continued enrollment and plan elections for the next plan year will be automatic unless written notice of a requested change or termination is received by MB prior to the next annual open enrollment date (January 1st). I may terminate this coverage by submitting a cancellation request in writing to plan administrator, MB or by completing the MB online Cancellation form at www.memberbenefits.com. I understand all terminations will be effective at 11:59pm on the last day of the month in which my Cancellation Request was submitted. I understand there are no partial month or back dated terminations. I understand refund requests may be granted only within the first 30 days after my coverage effective date. No later than 30 days after my coverage effective date, and only in the event that no claims have been paid or filed, I may request that my enrollment be deemed void, and any money paid will be refunded net of any surcharges or processing fees. I understand refund requests may take up to 30 days to process. I understand if I terminate this coverage or discontinue enrollment for any reason, I will not be permitted to re-enroll in this plan for a period of 24 months from the effective date of my coverage termination. I hereby apply for membership in the American Association of Business Networking (“ABN”). Upon completion of this enrollment form; and ABN's acceptance of my membership application; and payment of initial dues ($2.00 monthly), I understand that: (a) I may be eligible for certain member benefits available through my ABN membership; (b) these benefits may change from time to time; (c) My membership will become effective on the day this enrollment form is completed; (d) I may be eligible to apply for association group insurance; and (e) I authorize the release of my name and address listed on the Application for Insurance to ABN. To the best of my knowledge and belief, the information I’ve provided is complete and correct.

Signature*

[clear]

Use your mouse or finger to draw your signature above

Affiliated Organization

Association Member ID#

If an Employee, list your Employer's Member ID#

Annual Dental Premium $

Annual Vision Premium $

Annual MDLive Premium $

Annual ABN Dues $

ABN Monthly Dues $

Year End

Entry Month

Months

Effective Month Calc

Campaign Source

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Campaign Medium

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Campaign Term

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Campaign Content

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Campaign Name

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GCLID (Google Click Identifier)

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Progress

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Web Enrollment & Electronic Signature Agreement

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

Paper Copies

Withdrawal of Consent

Scope of Consent

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

Primary Enrollee Information

Primary Enrollee Identification

Dependent Information

Payment Information

IMPORTANT:

MEMBERBENEFITS48

IMPORTANT:

MEMBERBENEFITS

Enrollment/Membership/Administration Agreement