Continental Advantage Care Discount Program Application
Print Clearly To Ensure Correct Processing: Full Name - Address - Phone # - E-Mail
First Name__________________________________ MI ____ Last Name_______________________________ Mothers Maiden Name____________________________________ Primary Language English Spanish Address ________________________________________________________________ Apt #_______________ City : _____________________________________________ State:_________ Zip_____________-_________ Home Ph # _________- ____________________________Cell Ph # : __________- _______________________
Date of Birth
_______/_____/_______________
E-Mail _____________________________________________________
These Discount Benefits ARE NOT INSURANCE and ARE NOT INTENDED as a Substitute for or Replacement of Existing Insurance
Prescription Drugs - Save 15% to 55% @ 51,000 Pharmacy Nationwide + Mail Order Prescription Plan Dental Care - Save 15%- 50%+ @ 66,000+ Nationwide +Cleaning=s, X-rays + Fillings +Orthodontics + Periodontics
* Anticipated national average dental charges for the 2006 calendar year based on the comparison of provider negotiated fees to national average charges. Actual cost and savings vary by provider and geographical area. ** According to Aetna Provider Database as of March 1, 2006.
Vision Care - Save 20%- 60% @ 12,000+ Nationwide + Eyeglasses, Contact lenses, excluding disposables, bifocals + 10%-30 % off medical eye exams/ surgical procedures including LASIK Chiropractic - Save 30% to 50% @ 3,000 Chiropractors Nationwide, Diagnostic services & x-rays Network Physician Referral Save 10 % - 30% @ 285,000 + Physicians includes Primary Care & Specialists Includes: Physician Visits- Save 10% - 30% @ over 285,000 Physicians & Specialist Hospital Network - Save up to 25% @ over 70 % of the Hospitals & at Ancillary Facilities Nationwide. (Hospital discounts NOT available in Maryland ) Alternative Medicine - Save up to 30% @ 16,000 + Practitioners, Acupuncture, Nutritional Counseling, Massage Therapists & Holistic Medicine & Includes 35 Different Disciplines VIP Health - Vitamins - Nutritional supplements special discount savings. 10% discount on over 6000 products, Choose from brand names you know and trust, Country Life, Natures Way, Nordic, Garden of Life . Shop toll free or online with friendly & knowledgeable service reps, Includes: Diabetic Supplies- Save 15 % on supplies + Blood Glucose Testing Supplies (Liberty -diabetic) Nurse Hot Line 247-365 Toll FREE Access - Bi-Lingual Long- Term / Elder Care- Save 4% to 30 % - Assisted Living Facilities 55,000+ providers Nationwide Telephonic Counseling - Free unlimited telephone counseling services available 24 / 7 Save 20% to 35% @ 27,000 Providers Nationwide on referred licensed counselors. Counseling Services- provides comprehensive research and referral information for child care, elder care, and care for people with disabilities. Personalized provider profiles within 48-72 hours. Hearing Aids - Save 15% @ 1300 Hearing Centers, + Beltone Hearing Aids + Mail Order Hearing Aids Fitness Advantage – Access over 5000 International Fitness Club Network facilities nationwide at clubs lowest membership rate. Travel Assist - Emergency Evacuation when over 100 Miles From Home- Medical and Travel assistance Financial Wellness – Financial literacy Program, includes Debt Management Program, Debt Negotiation / Settlement Program, Tax Relief Offer in Comprise and Student Loan Consolidation with access to Certified Credit Counselors by phone and e-mail. Legal Services Includes : Free Phone Consultations & Free Will, + $ 75 Hourly Cap with 22,000 U.S. Attorneys
Added separate insurance benefit after 30 or more consecutive days of membership through CDAoA, at no additional cost. Accident Medical Expense Benefit : Covered Expenses Include : Accidental Death & Dismemberment : $ 5000. For each family member, at home, work, school, or play $ 100 deductible , per occurrence, per covered family member Hospital or Surgical Center Care, Prescription Drugs, Doctor Medical Treatment, X-rays & Lab exams, Therapeutic Services & Supplies, Nursing Care, Dental Treatment from Injury, Ambulance Services. $ 10,000. For each family member, including spouse, and all dependent
Form # CAC/ NBI 8786 pg 1 of 3
By signing the drafting authorization on page 2 of this membership application, I hereby acknowledge that I have read that the Continental Advantage Care plan is not insurance and is a discount fee-for service plan. Application Terms and Conditions
These Discount Medical Benefits ARE NOT INSURANCE and ARE NOT INTENDED as a Substitute for or Replacement of Existing Insurance This membership may include certain limited benefit group insured benefits. Benefits are offered at the sole discretion of CDAoA and may vary by availability, vendor or state of resident of member. I understand this application is being submitted in consideration for membership in the CDAoA. I hereby designate and appoint the Secretary of CDAoA in office at any particular time and from time to time as my proxy and my agent and attorney-in-fact to receive all notices of meetings of the members, to attend and vote in my behalf at any and all meetings of the members, to execute consents and to otherwise act for me in the same manner and with the same effect as if I were personally present. I authorize my proxy to substitute any other person to act under this proxy, to revoke any substitution, and to file this substitution or revocation with CDAoA. I understand that this proxy is a voluntary designated appointment and I have a right to receive all notices of meetings and to attend such meetings and vote thereat. In such event, I will notify the Secretary of CDAoA of my desires in this respect. For more information about CDAoA please visit www.cdaoa.org
Family Members Included
List Full Name: First Name , Middle Initial , Last Name , Date of Birth .
Spouse: First _______________________________MI_____Last _______________________ DOB________________ Child # 1 First _______________________________MI____ Last________________________DOB________________ Child # 2 First_______________________________MI_____Last________________________DOB________________ Child # 3 First_______________________________MI_____Last________________________DOB________________ Additional Membership Cards for immediate family members may be ordered for an additional fee of $ 2.50 per card Name on Card First________________________Last_________________________ Name on Card First________________________Last_________________________ Name on Card First________________________Last_________________________ Add Additional Card Fees to Initial Registration Fee $ ____________
Credit Card Debit: Initial $ 79.00 payment includes a one time $ 20.00 registration fee. I hereby authorize CAC/NBI to charge my credit card and automatically debit my monthly Payment of $ 59.00 On the 20th of each month for my next month’s Membership dues
Card Holder’s Name________________________________________________ VISA MASTERCARD
16 digit # I___I___I___I___I___I___I___I___I___I___I___I___I___I___I___I___I Exp ________________
3 digit code # on back of Credit Card # ____ ____ ____ Home Billing Zip _______________________________
Signature Required: X_______________________________________________ Date: ______/______/_____
Electronic Check Debit:
Initial $ 79.00 payment includes a one time $ 20.00 registration fee. I hereby authorize CAC/ NBI to Transfer Electronic Funds from the Financial Institution indicated below and authorize my Financial Institution (Bank, Savings/ Loan / Credit Union) to honor those transfers and automatically debit my monthly payment of $ 59.00 on the 20th of each month for my next month’s Membership dues.
Name on Account: ________________________________Account Type
Checking
Savings
Name of Bank_________________________________________Branch______________________ City & State ___________________________________________ Zip _______________________ ABA # 0 0 : I___I___I___I___I___I___I___I___I___I 0 0 : ACCOUNT # I___I___I___I___I___I___I___I___I___I___I___I___I___I___I___I___I
Signature Required: X______________________________________ Date:_____/______/_____ Form # CAC/ NBI 8786 pg 2 of 3
Introductory Membership Dues : Guaranteed not to increase for 36 Months
Additional Terms and Conditions- Electronic Bank Draft & Credit Card To terminate or cancel the member agreement, please call (800) 800-7616 or send a written notice to: New Benefits, 14240 Proton Road, Dallas, Texas, 75244.
This notice must be received at least three ( 3 ) days prior to my next scheduled payment date. This Agreement can be cancelled for non-payment.
IMPORTANT:
Using Bank Draft Payments CANNOT Be Processed Without A VOIDED CHECK or ENCODED DEPOSIT SLIP Tape Voided Check or Deposit Slip in this Area Funds Payable To: Continental Advantage Care
Mail To : P.O. Box 496 , Garrisonville , Va. , 22463
Applications
Date _____ /______ / ______ Money Order Visa # MasterCard # Personal Ck #
1-877-877-2202
For more information visit us @ WWW.Advantagecare.net or E-mail to : Info@advantagecare.net DISCLOURES: THIS IS NOT INSURANCE
This discount card program contains a 30 day cancellation period
All members enrolled in the Consumers Direct Association of America ( CDAoA ) are eligible to receive these benefits. The benefits under the Group Accidental Death & Dismemberment and Medical Care are underwritten by an A.M. Best rated insurance company and subject to the exclusions, limitations, terms and conditions of coverage as set forth in the insurance certificate provided in your membership materials and the Group Accidental Death and Dismemberment and Medical Care Insurance Policy ( Form No. G-19000) issued to CDAoA. These benefits are provided at CDAoA’s expense to all active members who are enrolled for 30 or more consecutive days as added separate benefits at no additional cost to the members.
A. B. C. D.
Discount Medical Plan Organization: New Benefits Ltd. 14240 Proton Rd. Dallas, TX.75244 Travel Assist Benefit not available to Florida and Washington residents. Pharmacy Discounts are Not Insurance, and are Not Intended as a Substitute for Insurance. Member shall receive a full refund of membership fees, excluding registration fees, if membership is cancelled within the first 30 days. E . This plan is not available to residents of : FL,HI, ND, SD, WA, NJ, MT, IN . Sponsoring Association : Consumers Direct Association of America ( CDAoA )
Reps Name: Ray Evans
Phone # 1-877-877-2202
ID # 8775
When mailing application enclose all three ( 3 ) pages with your original registration fee , TO : Continental Advantage Care, P.O. Box 496 , Garrisonville, VA. 22463
Form # CAC/ NBI 8786 pg 3 of 3