AGREEMENT DISCLOSURE
Terms and Conditions
Your application for plan benefits authorizes Comprehensive Insurance Agency, LLC to charge your credit card or checking account for the initial dues payment to start your plan benefits in the DentaSaver program. Comprehensive Insurance Agency, LLC will then charge your credit card or checking account each premium period. You must provide Comprehensive Insurance Agency, LLC 30 days written notice
if you wish to cancel this plan.
ENROLLMENT FEE
A one time, non-recurring enrollment fee of $15.00 will be added to
the first modal payment charge that appears on your credit card or bank statement.
Your TOTAL INITIAL PAYMENT CHARGE will be your chosen plan dues PLUS $15.00. All payments thereafter will be the chosen modal amount.
EFFECTIVE DATE
I
understand that my membership and plan benefits will not become effective, active and available
until the 1st day of the 1st month following receipt of this application by Comprehensive Insurance Agency, LLC.
REFUND POLICY
DentaSaver offers you a 30 day money back guarantee.
If for any reason you decide to cancel your membership within the first 30 days
after application or effective date (whichever is later), we will refund your
dues, no questions asked. After the 30 day period, if you have chosen the
quarterly, semi-annual or annual dues mode, the refund will be on a pro-rata
basis measured from the first day of the month FOLLOWING our receipt of your
written cancellation request.
AGREEMENT AND AUTHORIZATION
I/We have read, understand and agree to the terms and conditions above. I authorize Comprehensive Insurance Agency, LLC the authority to charge my credit card for all future renewal dues as they come due. I will notify Comprehensive Insurance Agency, LLC in writing of my wish to cancel
the membership 30 days in advance.
I/We have read, understand and agree to the terms and
conditions above. I/We hereby request and authorize you to pay checks drawn on
my account by Comprehensive Insurance Agency, LLC, and payable to same provided
there are sufficient collected funds in said account to pay the same upon
presentation. This authorization is to remain in effect until Comprehensive
Insurance Agency, LLC receives written notification from me revoking the
authorization
Plan exclusions: (1) Work in progress is not covered.
(2) Work in progress after enrollment on the dental plan must be completed
before selecting another participating dentist. (3) Any dental procedures performed
by a non-participating dentist are not covered. (4) Aetna Dental cannot guarantee
the continued participation of any dentist. If he/she leaves the plan, you will
need to select another dentist. (5) Not all types of dentists may be available
in your area; you may have to travel to receive care from a participating
general dentist or specialist. (6) Some providers may charge if you miss or
break appointments without prior notice. (7) Please verify that the dentist is a
participating provider when scheduling your appointment.
If you agree to these terms and conditions, please complete and print this form.
Sign and date the form and Fax both pages to 847-483-9485.
Please keep the original
for your records.
| Authorized Signature: ___________________________________ |
Date: _______________ |
If you prefer to mail the form, please send it to:
Comprehensive Insurance
3601 Algonquin Rd.
Suite 605
Rolling Meadows, IL 60008
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