Society for American Archaeology DISCOUNT DENTAL PLAN ENROLLMENT FORM The United States Life Insurance Company in the City of New York TO ENROLL: Send this completed form with your check payable to: ADMINISTRATOR SAA GROUP INSURANCE PROGRAM P.O. BOX 10374 Des Moines, IA 50306-8812 QUESTIONS? 1-800-424-9883 customerservice.service@mercer.com PLEASE PRINT IN INK OR TYPE - DO NOT USE CORRECTION FLUID OR GEL PEN - INITIAL AND DATE ANY CHANGES ENROLLEE Please print or type. Complete all areas, sign and date. Social Security # Name: Add 1: Add 2: City, St., Zip: Last First MI Date of Birth Phone Numbers (Mo./Day/Yr.) Sex G M G F ( ) Home ( ) Work E-Mail Mercer Consumer will not share your email information. MEMBER AFFILIATION I am a member of the Society for American Archaeology. G Yes G No Membership # Membership in SAA is required for participation in the plan. Eligibility Date (FOR OFFICE USE ONLY) SPOUSE INFORMATION Please complete only if you are enrolling your spouse for coverage. Spouse Name (First, Middle, Last name only if different) Date of Birth (Mo./Day/Yr.) Spouse's Social Security # Sex G M G F DEPENDENT CHILD(REN) INFORMATION Please complete only if you are enrolling your dependent child(ren) for coverage. If you desire coverage for more than two children, please attach a separate sheet including the information below. NAME OF CHILD (FIRST, MIDDLE, LAST NAME ONLY IF DIFFERENT) CHILD'S SOCIAL SECURITY # DATE OF BIRTH NAME OF CHILD (FIRST, MIDDLE, LAST NAME ONLY IF DIFFERENT) CHILD'S SOCIAL SECURITY # DATE OF BIRTH (Mo./Day/Yr.) SEX G M G F (Mo./Day/Yr.) SEX G M G F G-19477-FL 10530/10546/ 1018/51857 0000259-0000001-0000203
RATE AND BILLING OPTIONS - Please check one: Please select the type of coverage you would like. Enclose a check for the rate selected and mail it with this Enrollment Form to Mercer Consumer. Even if you select Automatic Check Withdrawal, you are required to send a check for your first month's premium along with a blank voided check. G Member Only Coverage G Family Coverage - including Member, Spouse and Child(ren) G Member +1 Dependent Coverage PLEASE READ AND SIGN I hereby enroll with The United States Life Insurance Company in the City of New York for coverage under The Discount Dental Plan for Society for American Archaeology Members. I have read and understand the conditions and exclusions of the program. I understand that the insurance applied for shall become effective on the first day of the month after receipt and acceptance of my Enrollment Form and first payment. Important Notice - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. MEMBER'S SIGNATURE X DATE X DE385E G-19477-FL *01290601000* Group Policy G-195,621 AG-11015 FLORIDA STATE SPECIFIC ENROLLMENT FORM 2/15 0000260-0000002-0000203
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The Discount Dental Program FOR SOCIETY FOR AMERICAN ARCHAEOLOGY MEMBERS AND THEIR FAMILIES QUALITY DENTAL CARE FOR YOUR ENTIRE FAMILY Dental coverage is an important health benefit especially if you have a family. As an association member, you can now get excellent dental treatment at discounted costs for yourself and your family through the SAA Discount Dental Plan. Whether you need treatment for current problems or to prevent serious diseases of the teeth or gums, this SAA Discount Dental Plan provides discounted fees for quality, professional dental care at an economical price. The SAA Discount Dental Plan offers the following special features: DENTAL CARE TO BRIGHTEN YOUR SMILE... PRICES TO BRIGHTEN YOUR DAY Dental services are provided by a nationwide network of independent participating dentists. You save money every time you go to the dentist. What's more, you'll receive the discount at the time of your visit. There are no claim forms or waiting for reimbursement. You'll enjoy immediate savings! AUTOMATIC ISSUE FOR MEMBERS AND THEIR FAMILIES Enrolling in the Plan is easy and automatic. There are no health questions and SAA members and their families cannot be turned down for coverage LITTLE OR NO CHARGE FOR DIAGNOSTIC PROCEDURES One of this Plan's most outstanding features is preventive care. Regular check-ups are extremely important to maintaining good health and preventing serious problems. That's why we've made it easy and economical for you to get the kind of preventive care that you and your family need. You and your family receive a free oral examination and any necessary x-rays, once per membership year, at no cost when received in conjunction with a paid annual check-up prophylaxis (cleaning)! That's a 100 percent instant discount for an annual oral exam with bitewing x-rays. (A fee may be charged in certain states.) The cost of basic teeth cleaning is substantially reduced as well. Refer to the fee schedule for a list of preventive services and reduced fees. HERE'S HOW THE PLAN WORKS Nationwide Network of Participating Dentists The SAA Discount Dental Plan is a reduced fee-for-service plan. Dental services are provided by a nationwide network of independent, participating dentists. That means you pay a specified fee for dental services performed by a dentist in the network. This fee is more economical than the standard fees. The fee schedule that follows lists the covered dental procedures and services, and their reduced fees. You will never pay more than the amount listed on your fee schedule for covered services. Any procedure not listed on the fee schedule will be reduced by 25 percent from the network dentist's usual and customary fee. With the SAA Discount Dental Plan, there is usually no charge for an annual oral examination and bitewing x-rays. For other charges, you can receive up to 60 percent reductions on dental fees, based on the national average fees. That's an instant discount each time you're treated by a panel dentist! 0000263-0000005-0000203
GREAT SAVINGS! The SAA Discount Dental Plan gives you and your family immediate savings. A family of four can save several hundred dollars per year on regular checkups alone for only $156 annually! As you can see, this Plan more than pays for itself in regular check-ups alone. Take a look at these sample procedures and the savings you receive under the Plan: ECONOMICAL ANNUAL COST The SAA Discount Dental Plan provides you and your family with hundreds of dollars worth of services and discounts for an inexpensive price. Take a look at the economical annual costs: CHOOSING A PLAN DENTIST You can choose any participating dentist you want in the network. And you can change your dentist at any time, for any reason. All of the dentists in the network are independent, participating dentists who have passed an extensive pre-screening evaluation. All dentists comply with the current standards of dental practice to help provide you and your family with quality dental care. No Referral Needed to See a Specialist The network includes many specialists such as oral surgeons, endodontists, periodontists and orthodontists. You do not need a referral to see a specialist. Simply choose any participating specialist in the network and you'll automatically receive a 25 percent reduction on the work the specialist performs. Choose from Over 6,000 Dentists Over 6,000 dentists across America participate in the dental network so you can select a dentist convenient to home or work. Our toll-free service number makes it easy to find a dentist or specialist near you. Even if you travel or move, just call the toll-free number to locate a plan dentist. To find a network dentist near you, just telephone 1-800-238-3884 toll-free. Dental Directory Services (DDS), Terms and Conditions 1. The dental services appearing in this schedule are available from general practitioners and specialists listed in the DDS Dental Directory. Any services that are not listed are available at a 25% discount from usual and customary fees charged by participating general practitioners and specialists, including pedodontics, prosthodontics and implantology. 2. Aside from the Annual Check-up, additional exams, x-rays and consultations are available at a 25% discount at general practitioners. All exams, x-rays and consultations at all specialists are 25% of the dentist's usual and customary fee. Invisalign braces are 25% of the dentist usual and customary fees. 3. All participating providers may charge an OSHA sterilization fee per visit and a lab fee for crown, bridges and denture work. 4. The administration of nitrous oxide intravenous sedation or general anesthesia is available at a 25% discount from usual and customary fees charged by the participating general practitioners and specialists. 5. Britesmile is not a covered procedure. 6. It is the Member's responsibility to verify that the dentist is a participating Provider for DDS before seeking any treatment. Any dental procedures performed by a non-participating dentist are not covered. 7. The dollar amount specified for each procedure may not be the only cost incurred for a given treatment. Many treatments may require more than one dental procedure. Please consult with your DDS provider for a detailed treatment plan before beginning any dental work. 8. DDS can not guarantee the continued participation of any dentist. If the dentist that you use leaves the plan, you will need to select another participating provider. Not all dental specialists are available in all areas. 9. While participating DDS providers are professionally licensed in the state in which they practice, DDS does not guarantee the quality of service of the providers. Any quality of care concerns involving any participating provider should be directed to the DDS Provider Relations Department. 10. Provider listings and/or fee schedules can be updated or changed without notice. *01310603000* 0000264-0000006-0000203
EFFECTIVE DATE SAA members and their families will become enrolled on the date their request for coverage is received and processed, provided they have made the first payment. If your enrollment material and contribution are received on the first through the fifteenth day of the month, the plan will take effect on the first of the following month. If your enrollment material and contribution are received on the sixteen through the thirty-first day of the month, the plan will take effect on the first day of the month following the month after receipt of contribution and enrollment material. RENEWAL PAYMENTS Once you are covered under the Plan, you will have a 31-day grace period for your payment of renewal contributions. EASY TO ENROLL... AND EASY TO USE 1. Refer to the Plan description for information and costs as you fill out the enrollment form. 2. Make a check payable for the total amount of the cost due payable to: Administrator, SAA Group Insurance Program. 3. Mail the completed enrollment form together with your check in the postage-paid envelope provided or to: Administrator, SAA Group Insurance Program Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 4. A personalized SAA Discount Dental Plan Identification Card will be sent to your home, along with a Fee Schedule and a list of participating dentists nearest to your zip code. Once you receive your I.D. card, you and your family are entitled to all of the discounted dental services in the program. To receive these discounts, just follow these three steps: A. Contact the participating network dentist of your choice to make an appointment. Appointments can usually be scheduled within a short period of time. B. When visiting your network dentist's office, present your SAA Discount Dental Plan I.D. card to the receptionist. C. After the session, pay your dentist directly according to the special economical fee on the enclosed fee schedule. AT YOUR SERVICE We want you to have the best possible service. For more information about a plan dentist or specialist near you, just call the service number below. 800-238-3884 The Discount Dental Plan is Provided By: The United States Life Insurance Company in the City of New York 3600 Route 66 P.O. Box 1580 Neptune, NJ 07754-1580 The most prominent independent ratings agencies continue to recognize The United States Life Insurance Company in the City of New York in terms of insurer financial strength. For current insurer financial strength ratings, please consult the Web site at www.americangeneral.com/ratings. Policies are issued by The United States Life Insurance Company in the City of New York (all states). The United States Life Insurance Company in the City of New York is responsible for the financial obligations of insurance products it issues and is a member of American International Group, Inc. (AIG). The Dental Plan is Administered By: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box 10374 Des Moines, IA 50306-8812 Questions? 1-800-424-9883 AR Ins. Lic. #100102691 CA Ins. Lic. #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC TX Ins. Lic. #1850385 This MN #40291395 discount program is not a health insurance policy and OK #100100336 is not intended as a substitute for insurance. The program This discount provides program for is not discounts a health insurance on Services policy from and is not participating intended as a substitute providers, for insurance. and thethe range program of the provides discounts for will discounts varyon depending Services from onparticipating the type ofproviders, and and the services range received. of the discounts The will program vary depending does not on make the type payments of provider toand providers services received. of health The program care services. does not make Members payments areto required providers to of health pay for care all services. healthmembers care services, are required butto will pay for receive all health a care discount services, but from will receive contracted a discount providers. from contracted providers. Group Policy G-195,621 2/15 DE385PA! 0000265-0000007-0000203
*01320604000* " 0000266-0000008-0000203
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*01330605000* $ 0000268-0000010-0000203
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The United States Life Insurance Company in the City of New York Copyright 2015 Mercer LLC. All rights reserved. Group Policy G-195,621 AG-11015 *01340606000* & 0000270-0000012-0000203