LRTA Dental & Vision Program Enrollment

Are you a member of this association? If not, please complete this application then visit your association's website to join.
Are you Retired?
Coverage must start at the beginning of a month.
LRTA Dental & Vision Program

Rates guaranteed through April 2019

Monthly Dental Rates:
Member: $47.60
Member + 1: $95.20
Family: $128.40

Monthly Vision Rates:
Member: $10.90
Member + 1: $18.85
Family: $23.60

Monthly Dental + Vision Coverage:
Member: $58.50
Member + 1: $114.05
Family: $152.00

Please select one of the following dental products.

Please provide the following information:
Please select one of the following vision products.
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.

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Authorization to honor drafts by the Association Member 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.
I understand that I am submitting an application for dental or vision insurance marketed by Association Member Benefits Advisors. Each application includes a one-time $20 enrollment 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 1.800.258.7041. 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 Member Benefits Advisors (AMBA). I understand that I will soon receive a 'Welcome to the Program' letter by mail.