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First Name	Last Name
Birth Date (mm/dd/yyyy) You Must Enter Your Birth Date

Please note that these policies will renew automatically each month until you call and cancel.

The policy provides dental and/or vision benefits only. Review your policy certificate carefully.

The policy provides limited benefits. Review your policy carefully.

The policy provides dental and/or vision benefits only. Review your policy certificate carefully. By submitting your application using this form, you hereby apply for coverage. This policy has limitations, exclusions, terms and conditions under which the policy may be continued in force or discontinued.

Ameritas Life Insurance Corp. | Underwritten by Ameritas Life Insurance Corp. | 5900 O Street Lincoln, NE 68510 |

Please note: Your insurance is effective on the date you selected during enrollment, but you may need to call for verification of benefits if you have an appointment during the first few days of coverage. Our application process may take up to five business days after your application is submitted. If you visit your dental or vision provider during that time, you may need to contact Ameritas customer service at (800) 300-9566 for verification of benefits.
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Ameritas, the bison design and "fulfilling life" are service marks or registered service marks of Ameritas Life, affiliate Ameritas Holding Company or Ameritas Mutual Holding Company.