{"table_id": "bug8y4dmf", "import_table_id": "bqujrve7u", "success_url": "https://example.com/success", "meta_data_fid": 61, "memberRelationship": "Member", "json_fid": 59, "test_fid": 75, "form_definition_fid": 64, "related_form_fid": 71, "related_application_fid": 444, "form_id": 9, "form_version": "v2", "layout": "v2", "top_banner": "mb_logo.png", "sub_banner": "buyinstantdental-logo.svg", "formBranding": "Buy Instant Dental \u2014 MetLife Dental & Vision Enrollment", "formTitle": "Buy Instant Dental \u2014 MetLife Dental & Vision Enrollment", "submitSuccessBanner": "

Congratulations! You've completed your ABN Metlife Dental/Vision enrollment application.

Please keep this confirmation for your records.

", "stripe": {"publishableKeys": {"test": "pk_test_yuMGZWVZSn0AtvhLtHR7jryy", "live": "pk_live_yafvran5qvLz4JwqwRDMZGE0"}}, "pages": [{"name": "Choose Your Coverage Options", "stepLabel": "Coverage", "sidebarContinueLabel": "Continue \u2192", "sections": [{"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "ratesIntro", "label": "", "visible": true, "content": "

Get quality PPO dental insurance from MetLife. Choose a dental plan, add optional vision and telehealth coverage, and enroll online in minutes.

"}]}], "cssClass": "pf-card pf-intro", "stepTitleInside": true}, {"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "ratesBandText", "label": "", "visible": true, "cssClass": "pf-band-lead", "content": "

Enter your ZIP code and choose a coverage start date to see your rates.

"}]}, {"fields": [{"type": "text", "import_fid": [16], "label": "ZIP Code", "quickbase_fid": "MemberZip", "required": true, "customPattern": "^\\d{5}$", "customValidationMessage": "Zip Code must be a 5 digit number."}]}, {"fields": [{"type": "monthDateSelect", "quickbase_fid": "CoverageStartDate", "label": "Coverage Start Date", "required": true, "startWithCurrentMonth": false, "monthsToShow": 2, "import_fid": [29], "hoverOverInfo": "Coverage begins on the 1st of the month you select, after receipt of your initial premium payment."}, {"type": "hiddenFormula", "quickbase_fid": "associationCode", "label": "", "import_fid": [154], "formula": {"fn": "url_param", "args": {"param": "association_code", "default": "BID"}}, "neverShowInSubmission": true}, {"type": "hiddenFormula", "quickbase_fid": "MonthsRemainingThisCoverageYear", "label": "Months in Initial Bill", "formula": {"fn": "months_remaining_this_coverage_year", "args": {"baseDateField": "CoverageStartDate"}}, "neverShowInSubmission": true}]}], "cssClass": "pf-card pf-rates-band"}, {"name": "", "columns": [{"fields": [{"quickbase_fid": "DentalCoverage", "type": "ratepicker", "requiredFields": {"zip": "MemberZip"}, "name": "Dental Insurance", "plans": ["AABN-DEN-HIGH-PPO-2027", "AABN-DEN-LOW-PPO-2027"], "required": true, "raterequired": true, "ratemultiplier": {"MonthsRemainingThisCoverageYear": "__useValue__"}, "premiumLabel": "per month", "DisplayMonthlyRate": true, "displayMode": "cards", "planChooser": true, "planChoiceLabel": "1. Choose a dental plan", "cardsTitle": "2. Select your coverage tier", "icon": "tooth", "carrierLabel": "Underwritten by Metropolitan Life Insurance Company, New York, NY 10166", "customDeclineMessage": "I decline Dental coverage.", "rateNoteTitle": "Dental Plan Information", "rateNote": "

100% coverage for exams and cleanings with no waiting period for preventive care. Save more when you visit a dentist in the MetLife PDP Plus network.

"}, {"quickbase_fid": "VisionCoverage", "type": "ratepicker", "requiredFields": {"zip": "MemberZip"}, "name": "Vision Insurance", "plans": ["AABN-VIS-HIGH"], "required": true, "raterequired": false, "ratemultiplier": {"MonthsRemainingThisCoverageYear": "__useValue__"}, "premiumLabel": "per month", "DisplayMonthlyRate": true, "displayMode": "cards", "cardsTitle": "Select your coverage tier", "icon": "eye", "carrierLabel": "Underwritten by Metropolitan Life Insurance Company, New York, NY 10166", "customDeclineMessage": "I decline Vision coverage.", "rateNoteTitle": "Vision Plan Information", "rateNote": "

Add vision to your dental plan: eye exams, glasses, contacts, lenses and frames.

"}, {"quickbase_fid": "TeleHealthCoverage", "type": "ratepicker", "name": "Telehealth", "plans": ["MDLIVE-0-COPAY", "MDLIVE-10-COPAY"], "required": true, "raterequired": false, "requiredFields": {"zip": "MemberZip"}, "ratemultiplier": {"MonthsRemainingThisCoverageYear": "__useValue__"}, "premiumLabel": "per month", "DisplayMonthlyRate": true, "displayMode": "cards", "cardShowsPlanName": true, "cardsTitle": "Select your telehealth plan", "iconSvg": "", "customDeclineMessage": "I decline Telehealth coverage."}]}]}, {"name": "", "columns": [{"fields": [{"quickbase_fid": "ratesummary", "type": "ratesummary", "label": "Your Plan Selections", "visible": true, "neverShowInSubmission": true}, {"type": "textbox", "quickbase_fid": "feesNoticeSummary", "label": "", "visible": true, "cssClass": "pf-fee", "content": "

Fee Notice

A required $2.00 monthly ABN association dues fee is added to your monthly billing and is not included in the rates shown. If you are already a dues-paying ABN member, this charge will not be added.

A one-time, non-refundable $20.00 enrollment processing fee is due at enrollment.

Monthly Auto-Pay (ACH) adds a $0.50 monthly draft fee.

"}, {"type": "textbox", "quickbase_fid": "needHelp", "label": "", "visible": true, "cssClass": "pf-help", "content": "

Questions?

Call to speak to our dental plan experts.

Phone: 1-800-282-8626
Hours: Mon\u2013Fri, 8:30a\u20135:00p ET

"}]}], "sidebar": true}, {"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "planDisclosures", "label": "", "visible": true, "cssClass": "pf-disclosures", "content": "

Important Information

The dental plans are subject to waiting periods for certain types of services. There is no waiting period for preventive care.

Savings from enrolling in a dental benefits plan featuring the MetLife Preferred Dentist Program will depend on various factors, including the cost of the plan, how often participants visit a dentist, and the cost of services rendered.

Rates are subject to change and depend on geographic area. Coverage may not be available in all states. See the plan summary for coinsurance, copayments, deductibles, exclusions and limitations.

This enrollment form is provided for summary purposes only and is not a complete description of the plan benefits, limitations and exclusions. Read your certificate of insurance for details.

"}]}], "cssClass": "pf-card pf-disclosures-card"}]}, {"name": "Web Enrollment & Electronic Signature Agreement", "stepLabel": "Electronic Consent", "sections": [{"name": "Electronic Consent Disclosure", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "eConsentNotice", "maxHeight": 320, "visible": true, "content": "

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.

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Billing Address

", "visible": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BillingStreetAddress1", "label": "Street Address 1", "required": false, "visible": false, "import_fid": [437]}]}, {"fields": [{"type": "text", "quickbase_fid": "BillingStreetAddress2", "label": "Street Address 2", "visible": false, "import_fid": [438]}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BillingCity", "label": "City", "required": false, "visible": false, "import_fid": [439]}]}, {"fields": [{"type": "select", "quickbase_fid": "BillingState", "label": "State", "required": false, "options": ["Alabama", "Alaska", "Arizona", "Arkansas", "California", "Colorado", "Connecticut", "Delaware", "District of Columbia", "Florida", "Georgia", "Hawaii", "Idaho", "Illinois", "Indiana", "Iowa", "Kansas", "Kentucky", "Louisiana", "Maine", "Maryland", "Massachusetts", "Michigan", "Minnesota", "Mississippi", "Missouri", "Montana", "Nebraska", "Nevada", "New Hampshire", "New Jersey", "New Mexico", "New York", "North Carolina", "North Dakota", "Ohio", "Oklahoma", "Oregon", "Pennsylvania", "Rhode Island", "South Carolina", "South Dakota", "Tennessee", "Texas", "Utah", "Vermont", "Virginia", "Washington", "West Virginia", "Wisconsin", "Wyoming", "American Samoa", "Guam", "Northern Mariana Islands", "Puerto Rico", "U.S. Virgin Islands"], "visible": false, "import_fid": [440]}]}, {"fields": [{"type": "text", "quickbase_fid": "BillingZip", "label": "ZIP Code", "required": false, "customPattern": "^\\d{5}$", "customValidationMessage": "ZIP Code must be a 5 digit number.", "visible": false, "import_fid": [441]}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "Occupation", "label": "Occupation", "required": true, "import_fid": [181]}]}, {"fields": [{"type": "text", "quickbase_fid": "Employer_Name", "label": "Employer Name (if employed)", "import_fid": [23]}]}]}]}, {"name": "Dependent Information", "stepLabel": "Dependents", "sections": [{"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "dependentsTitle", "label": "", "visible": false, "content": "

Please provide the information below for each dependent covered by the plans you selected.

"}, {"type": "textbox", "quickbase_fid": "noDependentsNeeded", "label": "", "visible": true, "content": "

You selected member-only coverage, so no dependent information is needed. Click Next to continue. To add a spouse or children, go back to the Coverage step and choose a different coverage tier.

"}, {"quickbase_fid": "Spouse", "type": "modal", "label": "Spouse / Domestic Partner", "minRecords": null, "maxRecords": 1, "fields": [{"quickbase_fid": "SpouseFirstName", "type": "text", "label": "First Name", "required": true, "import_fid": [228]}, {"quickbase_fid": "SpouseSecondName", "type": "text", "label": "Last Name", "required": true, "import_fid": [230]}, {"quickbase_fid": "SpouseDOB", "type": "date", "label": "Date of Birth", "required": true, "noFutureDates": true, "import_fid": [232]}, {"quickbase_fid": "SpouseGender", "type": "radio", "label": "Gender", "options": ["Male", "Female"], "required": true, "import_fid": [231]}], "visible": false, "required": false}, {"type": "modal", "quickbase_fid": "Children", "label": "Children", "fields": [{"type": "text", "quickbase_fid": "ChildFirstName", "label": "First Name", "required": true, "import_fid": [235, 238, 241, 244]}, {"type": "text", "quickbase_fid": "ChildLastName", "label": "Last Name", "required": true, "import_fid": [237, 240, 243, 246]}, {"type": "date", "quickbase_fid": "ChildDOB", "label": "Date of Birth", "required": true, "noFutureDates": true, "import_fid": [247, 248, 249, 250]}, {"type": "radio", "quickbase_fid": "ChildGender", "label": "Gender", "options": ["Male", "Female"], "required": true, "customRequiredMessage": "Please select the child's gender."}], "minRecords": null, "visible": false, "required": false}, {"quickbase_fid": "DomesticPartnerHelperText", "type": "textbox", "maxHeight": 200, "content": "

\n *Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.\n

", "label": "", "visible": false}]}]}]}, {"name": "Payment & Signature", "stepLabel": "Payment & Signature", "sections": [{"name": "Select Payment Type", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "PaymentDescription", "visible": true, "content": "

Payment Option 1: Monthly Auto Pay (ACH Bank Draft)
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).

", "label": ""}, {"type": "radio", "quickbase_fid": "paymentMethod", "required": true, "label": "Payment Method", "import_fid": [359], "options": ["Monthly Auto-Pay (ACH)", "Direct Annual Bill - Initial Payment via Credit Card"]}, {"type": "readonly", "quickbase_fid": "coverageStartDateDisplayTwo", "label": "Coverage Start Date", "listenTo": "CoverageStartDate", "hoverOverInfo": "Coverage begins on the first of the month following enrollment, unless otherwise stated.", "displayAs": "date", "visible": true, "alwaysShowInSubmission": true}]}]}, {"name": "Payment Information", "columns": [{"fields": [{"quickbase_fid": "Payment", "type": "payment", "label": "Payment", "currency": "usd", "visible": false, "statementDescriptor": "MB* MBR BNFT INSURANCE", "paymentSummaryLayout": "monthly-first", "planLabelStyle": "coverage-type", "ACHFirstTimeFees": [{"amount": 0.5, "description": "ACH Draft Fee"}, {"amount": 2, "description": "ABN Monthly Association Dues"}, {"amount": 20, "description": "One-Time Processing Fee"}], "ccOneTimeFees": [{"amount": 20, "description": "One-Time Processing Fee"}], "ccDirectBillRecurringFees": [{"amount": 2, "description": "ABN Monthly Association Dues"}], "ccMonthlyRecurringFees": [{"amount": 2, "description": "ABN Monthly Association Dues"}, {"amount": 2.75, "description": "Monthly Credit Processing Fee"}], "ccMonthlyFirstTimeFees": [{"amount": 20, "description": "One-Time Processing Fee"}], "requiredFields": {"zip": "Zip", "firstName": "FirstName", "lastName": "LastName", "email": "Email", "phone": "Phone", "address": "StreetAddress1", "address2": "StreetAddress2", "city": "City", "state": "State"}, "ratemultiplier": {"MonthsRemainingThisCoverageYear": "__useValue__"}, "paymentSummaryNotes": {"achMonthly": "Monthly Auto-Pay (ACH): your monthly payment includes the $2.00 ABN association dues and the $0.50 ACH draft fee.", "ccOneTime": "Credit Card one-time charge: this is the amount charged today for the remainder of the coverage year, plus the one-time $20.00 processing fee. You will be invoiced annually thereafter.", "default": "Total monthly rates: select a payment method to see exact charges."}}, {"type": "paymentsummary", "quickbase_fid": "PaymentSummary"}, {"type": "textbox", "quickbase_fid": "CreditAuthorizationNotice", "visible": false, "content": "

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.

", "label": ""}, {"quickbase_fid": "CreditAuthorizationCheck", "type": "checkbox", "label": "I Agree to the One Time Credit Card Payment Authorization.", "required": false, "visible": false, "customRequiredMessage": "You must Agree to the One Time Credit Card Payment Authorization", "prefill": false, "agreement": {"title": "One Time Credit Card Payment Authorization", "text": "CreditAuthorizationNotice"}}, {"type": "textbox", "quickbase_fid": "CCMonthlyAuthorizationNotice", "visible": false, "content": "

Monthly Credit Card Auto-Pay Authorization

I authorize Member Benefits to charge my credit card each month for the premium amounts due for the coverage elected herein, beginning on my Coverage Effective Date. I understand a one-time $20.00 processing fee will be included on my first bill. This authorization remains in effect until I revoke it in writing and Member Benefits has had reasonable time to act upon my request.

", "label": ""}, {"quickbase_fid": "CCMonthlyAuthorizationCheck", "type": "checkbox", "label": "I Agree to the Monthly Credit Card Auto-Pay Authorization.", "required": false, "visible": false, "customRequiredMessage": "You must agree to the Monthly Credit Card Auto-Pay Authorization.", "prefill": false, "agreement": {"title": "Monthly Credit Card Auto-Pay Authorization", "text": "CCMonthlyAuthorizationNotice"}}, {"type": "text", "quickbase_fid": "BankAccountHolderName", "label": "Accountholder's Name", "visible": false, "required": false, "import_fid": [38], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BankName", "label": "Name of Bank or Financial Institution", "visible": false, "required": false, "import_fid": [36], "prefill": false}]}, {"fields": [{"type": "select", "quickbase_fid": "BankAccountType", "label": "Account type", "options": ["Checking", "Savings"], "visible": false, "required": false, "import_fid": [37], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "text", "quickbase_fid": "BankRoutingNumber", "label": "Routing number", "visible": false, "required": false, "customPattern": "^\\d{9}$", "customValidationMessage": "Routing number must be 9 digits.", "sensitive": "achRouting", "import_fid": [39], "prefill": false}]}, {"fields": [{"type": "text", "quickbase_fid": "BankAccountNumber", "label": "Account number", "visible": false, "required": false, "customPattern": "^\\d{4,17}$", "customValidationMessage": "Account number must be 4\u201317 digits.", "sensitive": "achAccount", "import_fid": [35], "prefill": false}]}]}, {"name": "", "columns": [{"fields": [{"type": "image", "quickbase_fid": "CheckingGuideImage", "label": "", "relativeUrl": "/static/formImages/checkImage.png", "alt": "Routing Number Account Number Help Image", "maxWidth": 400, "visible": false, "neverShowInSubmission": true}]}]}, {"name": "", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "ACHAuthorizationNotice", "visible": false, "content": "

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.

", "label": ""}, {"quickbase_fid": "ACHAuthorizationCheck", "type": "checkbox", "label": "I Agree to the Monthly Auto Pay Authorization.", "required": false, "visible": false, "customRequiredMessage": "You must Agree to the Monthly Auto Pay Authorization", "prefill": false, "agreement": {"title": "Monthly Auto Pay Authorization", "text": "ACHAuthorizationNotice"}}]}]}, {"name": "Acknowledgment and Signature", "columns": [{"fields": [{"type": "textbox", "quickbase_fid": "AcknowledgmentText", "visible": true, "maxHeight": 320, "content": "

By signing below, I acknowledge:

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 eligibility requirements and will notify me if rejected. Otherwise, my coverage will be 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 enrollment if verification of eligibility or receipt of initial payment cannot be confirmed. All premium payments, coverage changes, and cancellation requests must be submitted directly to MB in writing or through the proper web form. 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 through December 31st. My elections remain in effect until the next annual open enrollment date (January 1st). My enrollment will automatically continue unless MB receives written notice of changes before the next annual open enrollment date.

I may terminate coverage by submitting a written cancellation request to MB or by completing the MB online cancellation form at www.memberbenefits.com. Terminations become effective at 11:59 pm on the last day of the month in which my request was submitted. No partial-month or backdated terminations are permitted.

Refund requests may be granted only within the first 30 days after my coverage effective date - and only if no claims have been paid or filed. Refunds will be issued net of surcharges or processing fees and may take up to 30 days.

If I terminate or discontinue enrollment, I understand I may not re-enroll for 24 months from the date of termination.

I hereby apply for membership in the American Association of Business Networking (\"ABN\"). Upon completion of this enrollment form, 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;
(b) these benefits may change from time to time;
(c) my membership becomes effective the day this form is completed;
(d) I may be eligible to apply for association group insurance; and
(e) I authorize release of my name and address from the Application for Insurance to ABN.

To the best of my knowledge and belief, the information I've provided is complete and correct.

I agree to conduct business with the Plan Administrator, Member Benefits. I have read and agree to the Member Benefits Administration Terms & Agreements.

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