1 Tell Us About Yourself

Are you a member of GREA?

Yes

Not a member yet? No problem.
These plans are available to members of GREA only so you will receive a call in the next 2-3 business days with instructions on becoming a member. You can also become a member by visiting www.garetirededucators.org.

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

2 Choose Your Coverage

Coverage Start Date

Coverage must start at the beginning of the month.

Dental Product

Rates good through Jun 30, 2021

Member Only: $55.32

Member + One: $110.77

Member + Family: $149.60

Plan Coverage »

Select Number Of People Covered

Prior Dental Carrier Name

Have you had dental coverage within the past 60 days?

Yes

Vision Product

Rates good through Jun 30, 2023

Member Only: $13.80

Member + One: $26.40

Member + Family: $29.34

Plan Details »

Select Number Of People Covered

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.

A one time $20 application fee applies.

Information for Dependent 1

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 2

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 3

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 4

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 5

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 6

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 7

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 8

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 9

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

Information for Dependent 10

Coverage

First Name

Middle Name

Last Name

Date of birth

Gender

Male

Female

SSN

Relationship

3 Billing Information

Credit or Debit Card

Bank Draft (ACH)

Bank Account Information

Account Type

Checking

Savings

Account Holder First Name

Account Holder Last Name

Routing Number

Confirm Routing Number

Account Number

Confirm Account Number

Billing Information

Same as Enrollment Information

Credit/Debit Card Information

Name On Card

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

I hereby authorize you to initiate debit entries on my account. This authority is to remain in effect until revoked by me in writing and until AMBA receives such notice. I agree that AMBA shall be fully protected in honoring such debt. Non-payment of insurance premium(s) results in the forfeiture of insurance. I authorize future increases and/or decreases in the cost of the plan(s) I selected to be automatically deducted without further authorization from me.

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

Terms and Conditions

I understand that I am submitting an application for dental or vision insurance marketed by Association Members Benefits Advisors. Each application includes a one-time $20 application 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 1-844-385-4359. 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).

I agree to the terms and conditions

Notes/Promo Code

Dental & Vision Enrollment Form

Exclusively From AMBA & GREA!

1

Tell Us About Yourself

Are you a member of GREA?

Date of birth

Gender

2

Choose Your Coverage

Coverage Start Date

Dental Product

Platinum Plan Dental Coverage

Have you had dental coverage within the past 60 days?

Vision Product

Details for Vision Plan

Number of Dependents

Information for Dependent 1

Coverage

Date of birth

Gender

Information for Dependent 2

Coverage

Date of birth

Gender

Information for Dependent 3

Coverage

Date of birth

Gender

Information for Dependent 4

Coverage

Date of birth

Gender

Information for Dependent 5

Coverage

Date of birth

Gender

Information for Dependent 6

Coverage

Date of birth

Gender

Information for Dependent 7

Coverage

Date of birth

Gender

Information for Dependent 8

Coverage

Date of birth

Gender

Information for Dependent 9

Coverage

Date of birth

Gender

Information for Dependent 10

Coverage

Date of birth

Gender

3

Billing Information

Bank Account Information

Billing Information

Credit/Debit Card Information

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

Terms and Conditions

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