2. Care Choice, providing you
with affordable quality healthcare
Our mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE association
group insurance, 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 healthcare value at a
reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with CARE CHOICE:
HOSPITAL PATIENT ADVOCACY WORLDWIDE $10,000 WORLDWIDE EMERGENCY
We work hard to lower your ACCIDENTAL INJURY TRAVEL ASSISTANCE
hospital bills! You will be protected from virtually 100% coverage for worldwide
ANY injury! air ambulance needs up
ROADSIDE ASSISTANCE to $100,000!
Keep your mind at ease and your car
on the road!
WORLDWIDE $10,000 ACCIDENTAL
DEATH & DISMEMBERMENT
Protect your family from
PET CARE unexpected expenses!
Protect that “other” family member,
YOUR PET!
$15,000 TERM LIFE /
$15,000 ACCIDENTAL
LEGAL SERVICES
DEATH & DISMEMBERMENT
Legal advice at your fingertips!
Lessen the burden on your
loved ones!
$50 DOCTOR OFFICE
VISIT REIMBURSEMENT
Don’t use emergency rooms for
primary care! Visit your Physician
UP TO 5 times per family member
per year.
AWIS030_CARECHOICE_PITCHBROCHURE_ENGLISH
REV:01.11.2011
3. SPONSOR & ENROLLER INFORMATION FOR OFFICE USE ONLY
Sponsor Name: 2 3 4 5 6 7
IMA/MSA #:
10878 Westheimer Rd., Suite # 191, Houston, TX 77042
Phone: 1.866.365.5829 Fax: 1.866.837.4556
Date:
Enroller Name:
MEMBER APPLICATION
IMA/MSA #: CARE ChOICE
PLAN SERVICES
Fees and Dues: • Hospital Patient Advocacy • $50 Physician Office • $15K Term Life Insurance/
• Roadside Assistance Visit Reimbursement * $15K Accidental Death
• Monthly Dues: $109.95 • $10K Accidental Injury † & Dismemberment ‡
• Pet Care
• One-Time Application Fee: $100 • $10K Accidental Death • Emergency§Travel
• Legal Services Assistance
& Dismemberment †
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: $ 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. I understand I am eligible for a refund of my membership dues if I cancel in writing by fax or mail within 30 days from postmark on my membership packet
plus five (5) days.
‡ 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.)
AWIS030_CAreChoICe_App rev:08.23.2011
4. AGREEMENT OF TERMS & CONDITIONS (PLEASE PRINT CLEARLY)
I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Care Choice member. I further understand that by joining the
Care Choice 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.
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 date of the postmark on the member fulfillment package, plus five (5) days,
Insurance Services (AWIS), a licensed insurance agency. Not available in AK, AR, and will receive a refund of membership dues paid. The one-time enrollment
CO, CT, GA, GU, KS, LA, MA, MD, ME, MN, MT, NC, ND, NE, NH, NJ, NY, OK, OR, fee is held as a non-refundable processing fee ** . The cancellation effective
PR, RI, SD, VI, VT, and WA. date shall be the date of the postmark if sent by mail and the business day of
receipt if sent by facsimile transmission. Members should allow three (3) to four
Cancellation Policy (4) weeks for their refund. Members may cancel their membership at any time
after the first thirty (30) ¶ days, provided American Workers Insurance Services
American Workers Insurance Services membership renews automatically by is given a written notice of cancellation. Membership package and cards must
continuing the payment of the monthly membership dues. There is no renewal be returned upon cancellation. It may take up to fourteen (14) to thirty (30) days
fee. In addition to paying monthly, the membership dues can be paid quarterly, after receiving a valid cancellation request for collection of dues to stop.
semi-annually, or annually. If the member wishes to change their billing cycle,
they should contact American Workers Insurance Services at 1.866.365.5829. ¶ Forty-five (45) days in California.
American Workers Insurance Services members may cancel their membership ** Fully refundable in Tennessee. $30 of the enrollment fee will be non-refundable in CA, IL, IN, SC,
in writing without giving a reason during the first thirty (30) ¶ days from the and TX.
LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES
* $50 Physician Office Visit Reimbursement: Association group insurance benefit provided ‡ $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group
through an insurance policy (AH 24230-003) issued and underwritten by United States Fire insurance benefits provided through an insurance policy (67432) issued and underwritten by
Insurance Company. ReliaStar Life Insurance Company.
† $10K Accidental Injury and $10K Accidental Death & Dismemberment: Association group § Emergency Travel Assistance: Association group insurance benefit provided through an
insurance benefits provided through a blanket special risk insurance policy (GA 26932-003) Agreement with the Lifeguard Emergency Travel Corporation and a group insurance policy
issued and underwritten by United States Fire Insurance Company. (RNMWC1003634) issued and underwritten by Lloyd's of London.
Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042
