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an affordable solution to match your healthcare needs OPTIMA CARE DELUXE

Optima Care Deluxe

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www.dmejia.awiscard.com Our mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE association group insurance, backed by the best customer service in the industry. That is why each of our plans has been carefully created with select services and group benefi ts to offer you an exceptional healthcare value at a reasonable cost.

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Page 1: Optima Care Deluxe

an affordable solution to match your healthcare needs

OPTIMA CARE DELUXE

an affordable solutionaffordable solution to match your to match your healthcare needs

OPTIMA CARE DELUXE

Page 2: Optima Care Deluxe

HOSPITAL PATIENT ADVOCACY We work hard to lower your hospital bills!

ROADSIDE ASSISTANCE Keep your mind at ease and your caron the road!

PET CARE Protect that “other” family member, YOUR PET!

LEGAL SERVICES Legal advice at your fi ngertips!

$50 DOCTOR OFFICE VISIT REIMBURSEMENT Don’t use emergency rooms for primary care! Visit your PhysicianUP TO 5 times per family memberper year.

HOSPITALIZATION (inpatient

hospital stay)

Pays $300 per day, up to 31 days per person per year.

INTENSIVE CARE / CARDIAC CARE UNIT (ICU/CCU)

Pays $600 per day, up to 31 days per person per year.

• Maximum benefi t for all Hospital & ICU/CCU confi nements: 31 days per year.

WORLDWIDE $10,000 ACCIDENTAL INJURY You will be protected from virtually ANY injury!

WORLDWIDE $10,000 ACCIDENTAL DEATH & DISMEMBERMENT Protect your family from unexpected expenses!

$15,000 TERM LIFE / $15,000 ACCIDENTAL DEATH & DISMEMBERMENT Lessen the burden on yourloved ones!

$5,000 CRITICAL ILLNESS Pays $5,000 when member is diagnosed with one of these critical conditions:

• Life Threatening Cancer

• Heart Attack

• Renal (Kidney) Failure

• Stroke

• Coma

• Coronary Artery Bypass Graft

• Loss of Sight, Speech or Hearing

• Major Organ Transplant

• Paralysis

• Severe Burn

WORLDWIDE EMERGENCY TRAVEL ASSISTANCE 100% coverage for worldwide air ambulance needs up to $100,000!

Optima Care Deluxe, providing you with affordable quality healthcare

Our mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE association

group insurance, backed by the best customer service in the industry. That is why each of our plans has

been carefully created with select services and group benefi ts to offer you an exceptional healthcare

value at a reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with

OPTIMA CARE DELUXE:

HOSPITAL PATIENT ADVOCACY We work hard to lower your hospital bills!

ROADSIDE ASSISTANCE Keep your mind at ease and your caron the road!

PET CARE Protect that “other” family member, YOUR PET!

LEGAL SERVICES Legal advice at your fi ngertips!

$50 DOCTOR OFFICE VISIT REIMBURSEMENT Don’t use emergency rooms for primary care! Visit your PhysicianUP TO 5 times per family memberUP TO 5 times per family memberUP TO 5per year.

HOSPITALIZATION (inpatient

hospital stay)

Pays $300 per day, up to 31 days per person per year.

INTENSIVE CARE / CARDIAC CARE UNIT (ICU/CCU)

Pays $600 per day, up to 31 days per person per year.

• Maximum benefi t for all Hospital & ICU/CCU confi nements: 31 days per year.

WORLDWIDE $10,000 WORLDWIDE $10,000 ACCIDENTAL INJURY ACCIDENTAL INJURY You will be protected from virtually ANY injury!ANY injury!ANY

WORLDWIDE $10,000 ACCIDENTAL DEATH & DISMEMBERMENT Protect your family from unexpected expenses!

$15,000 TERM LIFE / $15,000 ACCIDENTAL DEATH & DISMEMBERMENT Lessen the burden on yourloved ones!

$5,000 CRITICAL ILLNESS Pays $5,000 when member is diagnosed with one of these critical conditions:

• Life Threatening Cancer

• Heart Attack

• Renal (Kidney) Failure

• Stroke

• Coma

• Coronary Artery Bypass Graft

• Loss of Sight, Speech or Hearing

• Major Organ Transplant

• Paralysis

• Severe Burn

WORLDWIDE EMERGENCY TRAVEL ASSISTANCE 100% coverage for worldwide air ambulance needs up to $100,000!

Optima Care Deluxe,Optima Care Deluxe, providing you providing you with affordable quality healthcare with affordable quality healthcare

Our mission has always been to provide our members with a SIMPLE-TO-USE and SIMPLE-TO-USE and SIMPLE-TO-USE COST-EFFECTIVE association

group insurance, backed by the best customer service in the industry. That is why each of our plans has

been carefully created with select services and group benefi ts to offer you an exceptional healthcare

value at a reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with

OPTIMA CARE DELUXE:

AWIS031_O

PTIMA

CARED

ELUXE_PITCH

BROCH

URE_EN

GLISH

REV:01.11.2011

Page 3: Optima Care Deluxe

10878 Westheimer Rd., Suite # 191, Houston, TX 77042Phone: 1.866.365.5829 Fax: 1.866.837.4556

AWIS031_OPTIMACAREDELUXE_APP RE V:03.10.2011

MEMBER INFORMATION (PLEASE PRINT CLEARLY)

Last Name: First Name: M.I. D.O.B:

Mailing Address:

Apt #: City: State: Zip:

Gender: Language:

E-mail: Home Phone #:

Cell Phone #: Work Phone #:

Fax #: Bene� ciary:

MEMBER'S FAMILY INFORMATION (PLEASE PRINT CLEARLY)

Spouse’s First Name: Last Name: D.O.B:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship: (For additional dependents, add additional sheets)

BILLING INFORMATION (PLEASE SELECT ONLY ONE METHOD OF PAYMENT)

One-Time Application Fee: $ Monthly Dues: $ Total: $

Bank Draft or Debit: (check only one) Checking Savings

Name of Account Holder: Bank Name:

Bank Transit #: Bank Account #:

Credit Card: (check only one) VISA American Express Discover MasterCard

Name of Account Holder:

Account #: Expiration Date: CVV2 #: (The CVV2 # is the last 3 digits next to the signature line on the back of your credit card; or the 4 digits after your account # for American Express)

I have read the terms, conditions, and disclosures on the back of this application and authorize American Workers Insurance Services or its designated attorney-in-fact to electronically draft my account or bill my credit card indicated on this application for my one-time initial application fee and my membership recurring dues. I understand I am eligible for a refund of my membership dues if I cancel in writing by fax or mail within 30 days from postmark on my membership packet plus � ve (5) days.

Check this box if you are paying for this membership and are not the member.

X Date: Signature of the Depositor or Credit Card Holder (Must be signed by employer if employer is paying the membership dues.)

SPONSOR & ENROLLER INFORMATION

Sponsor Name:

IMA/MSA #:

Enroller Name:

IMA/MSA #:

Date:

FOR OFFICE USE ONLY

2 3 4 5 6 7

MEMBER APPLICATIONOPTIMA CARE DELUXE

PLAN SERVICES

• Individual* Monthly Dues: $169

• Family * Monthly Dues: $199

• One-Time Application Fee: $100

Fees and Dues: • Hospital Patient Advocacy• Roadside Assistance• Pet Care• Legal Services• $50 Physician Of� ce

Visit Reimbursement †

• Hospitalization ($300 per day Hospital; $600 per day ICU/CCU)†

• $10K Accidental Injury ‡

• $10K Accidental Death & Dismemberment ‡

• $15K Term Life Insurance/$15K Accidental Death & Dismemberment §

• $5K Critical Illness¶

• Emergency Travel Assistance**

Page 4: Optima Care Deluxe

Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042

AGREEMENT OF TERMS & CONDITIONS (PLEASE PRINT CLEARLY)

I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Optima Care Deluxe member. I further understand that by joining the Optima Care Deluxe program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPP association and at no additional cost to me, I am entitled to limited association group insurance bene� ts after a waiting period; for speci� c bene� t waiting periods, call Member Services at 1.866.365.5829. These limited association group insurance bene� ts are not comprehensive health insurance.

I understand that I have purchased a membership in AWIS from , IMA/MSA # .

I have read and understand the cancellation policy and disclosures set forth below.

X Date: Signature

PROGRAM DISCLOSURES

The program‘s services and group bene� ts are marketed by American Workers Insurance Services (AWIS), a licensed insurance agency. Not available in AK, CO, CT, FL, GA, GU, KS, MA, MD, ME, MN, MT, ND, NH, NJ, NY, OR, VA, PR, SD, VI, VT, and WA.

Cancellation Policy

American Workers Insurance Services membership renews automatically by continuing the payment of the monthly membership dues. There is no renewal fee. In addition to paying monthly, the membership dues can be paid quarterly, semi-annually, or annually. If the member wishes to change their billing cycle, they should contact American Workers Insurance Services at 1.866.365.5829. American Workers Insurance Services members may cancel their membership in writing without giving a reason during the � rst thirty (30)†† days from the

date of the postmark on the member ful� llment package, plus � ve (5) days, and will receive a refund of membership dues paid. The one-time enrollment fee is held as a non-refundable processing fee‡‡. The cancellation effective date shall be the date of the postmark if sent by mail and the business day of receipt if sent by facsimile transmission. Members should allow three (3) to four (4) weeks for their refund. Members may cancel their membership at any time after the � rst thirty (30)†† days, provided American Workers Insurance Services is given a written notice of cancellation. Membership package and cards must be returned upon cancellation. It may take up to fourteen (14) to thirty (30) days after receiving a valid cancellation request for collection of dues to stop.

* Applies to the Hospital/ICU/CCU, Term Life, and Critical Illness bene� ts.

†† Forty-� ve (45) days in California.

‡‡ Fully refundable in Oklahoma and Tennessee. $30 of the enrollment fee will be non-refundable in CA, IL, IN, LA, SC, and TX.

LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES

† $50 Physician Of� ce Visit Reimbursement and Hospitalization / Intensive Care: Association group insurance bene� ts provided through an insurance policy (AH 24230-003) issued and underwritten by United States Fire Insurance Company.

‡ $10K Accidental Injury and $10K Accidental Death & Dismemberment: Association group insurance bene� ts provided through a blanket special risk insurance policy (GA 26932-003) issued and underwritten by United States Fire Insurance Company.

§ $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group insurance bene� ts provided through an insurance policy (GL-855025) issued and underwritten by Hartford Life and Accident Insurance Company.

¶ $5K Critical Illness: Association group insurance bene� t provided through an insurance policy (CI 9600208) issued and underwritten by National Union Fire Insurance Company of Pittsburgh, PA. If individual option is selected, Critical Illness includes primary member only. If family option is selected, both the primary member and spouse are included.

** Emergency Travel Assistance: Association group insurance bene� t provided through an Agreement with the Lifeguard Emergency Travel Corporation and a group insurance policy (HTP 05209) issued and underwritten by Virginia Surety Company, Inc.