2. Platinum Select TL, 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
PLATINUM SELECT TL:
HOSPITAL PATIENT ADVOCACY WORLDWIDE $5,000 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!
AWIS032_PLATINUMSELECTTL_PITCHBROCHURE_ENGLISH
REV:01.11.2011
3. SPONSOR & ENROLLER INFORMATION FOR OFFICE USE ONLY
Sponsor Name: Daniel Mejia 2 3 4 5 6 7
IMA/MSA #: 43848 10878 Westheimer Rd., Suite # 191, Houston, TX 77042
Phone: 1.866.365.5829 Fax: 1.866.837.4556
Date:
Enroller Name: Daniel Mejia MEMBER APPLICATION
IMA/MSA #: 43848 PLATINUM SELECT TL
PLAN SERVICES
Fees and Dues: • Hospital Patient Advocacy • $10K Accidental Death • Emergency‡Travel
• Roadside Assistance & Dismemberment * Assistance
• Individual Monthly Dues: $69.95 • Pet Care • $15K Term Life Insurance/
• Family Monthly Dues: $79.95 $15K Accidental Death
• Legal Services & Dismemberment †
• One-Time Application Fee: $100 • $5K Accidental Injury *
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:
(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.)
AWIS032_PlAtInumSelecttl_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 Platinum Select TL member. I further understand that by joining
the Platinum Select TL 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 Daniel Mejia ,
IMA/MSA # 43848 .
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 receive a refund of membership dues paid. The one-time enrollment fee is held
Insurance Services (AWIS), a licensed insurance agency. Not available in AK, CO, as a non-refundable processing fee ¶. The cancellation effective date shall be
CT, GA, GU, MA, MD, ME, MN, MT, ND, NE, NY, OK, PR, SD, VI, and VT. 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 (4) weeks
Cancellation Policy for their refund. Members may cancel their membership at any time after the
first thirty (30)§ days, provided American Workers Insurance Services is given
American Workers Insurance Services membership renews automatically by
a written notice of cancellation. Membership package and cards must be
continuing the payment of the monthly membership dues. There is no renewal
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, LA,
in writing without giving a reason during the first thirty (30)§ days from the date SC, and TX.
of the postmark on the member fulfillment package, plus five (5) days, and will
LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES
* $5K 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.
† $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group
insurance benefits provided through an insurance policy (67432) issued and underwritten by
ReliaStar Life Insurance Company.
Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042
