MOA Dental, Vision & Hearing Plan

ManhattanLife Assurance Company of America

10777 Northwest Freeway, Houston, TX 77092

Dental, Vision, and Hearing Insurance Application

WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto maybe committing a fraudulent insurance act, which is a crime.

The insurance shall not take effect unless and until the application has been accepted and approved by ManhattanLife Assurance Company of America (Company), the full first premium has been paid, and the policy has been delivered to the applicant; and, (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing.

This application is for individuals and families (up to 5 persons, applicant and 4 dependents). If you will need to add more than 4 dependents, please contact info@moaia.net for a different form to fit your needs.
Did you hear about the MOA DVH from an insurance agency or optometry office?*

YesNo
If yes, please provide us with the name of the agency, agent or office.
As part of our referral program, please include business name and the employee who shared information with you so we can recognize them. (i.e. Small Town Eyecare, Jane Doe.)
APPLICANT INFORMATION
Today's Date

MonthDayYear
Today's Date

MonthDayYear
Month of the Year
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Age*
Gender (M/F)*
Address*
Street Address
City*
State*
Postal / Zip Code
Telephone Number*
Email Address*
example@example.com
Social Security Number*
Requested Effective Date

MonthDayYear
The first day of the month following the receipt of completed application. (e.g. applying on September 19, requested effective date is October 1). The applications take 5-7 days to process and cannot be processed on the 29th, 30th or 31st of the month due to internal processing restrictions.
How did you hear about the MOA DVH? Check all that apply.

MOA DVH WebsiteFacebookInstagramFriend/FamilyDoctor/DentistInsurance AgentEmployerOther
DEPENDENT(S) INFORMATION

Family Coverage is up to 5 persons. IMPORTANT: If you have more than 4 dependents to add, please contact us for a different form. If you are only adding a spouse to your application, it may be more cost effective to have them apply as an individual applicant. Please contact info@moaia.net if you need further guidance.
Do you have dependents to add to this application for a Family Coverage Plan?*

YesNo
Dependent 1 (Print Full Name)
First, Middle, Last Name
Social Security Number
Gender
Date of Birth

MonthDayYear
Do you need to add another dependent?

YesNo
Dependent 2 (Print Full Name)
First, Middle, Last Name
Social Security Number
Gender
Date of Birth

MonthDayYear
Date
Do you need to add another dependent?

YesNo
Dependent 3 (Print Full Name)
First, Middle, Last Name
Social Security Number
Gender
Date of Birth

MonthDayYear
Do you need to add another dependent?

YesNo
Dependent 4 (Print Full Name)
First, Middle, Last Name
Social Security Number
Gender
Date of Birth

MonthDayYear
Do you need to add another dependent?

YesNo
This form is currently only formatted for families of no more than 5 people. Please contact info@moaia.net for a personalized form to fit your needs.
GENERAL QUESTIONS
1. (a) Do you, or any proposed insured persons, have any dental, vision, or hearing insurance currently in force?*

YesNo
(b) Is the insurance applied for intended to replace any existing insurance with this or any other company?*

YesNo
If "Yes", provide type of contract or policy number, and name of company:
(c) If replacement is involved, have you received a replacement form (in states where required by law)?*

YesNo
COVERAGE INFORMATION
Coverage Applied For*

Applicant OnlyFamily (Family Coverage is up to 5 Persons/Dependent Section Required)Single Parent + One Child Only
Policy Year Maximum*

$1,000$1,500
Monthly Premium (USD):
Premium will be auto-calculated in USD based on age, coverage type and policy year maximum.
Premium (LISTBILL)
Premium will be auto-calculated based on age, coverage type and policy year maximum.
BILLING
Please select the appropriate Payment Authorization:

Monthly Automatic Bank Draft (Electronic Funds Transfer)Bill Me Directly
Monthly Automatic Bank Draft (Electronic Funds Transfer)

I (we) hereby authorize ManhattanLife Assurance Company of America (Company) to initiate debit entries to the account and depository, hereinafter called Depository, to debit the same to such account. This authority is to remain in full force and effect until Company and Depository have received written notification from me (or either of us) of its termination in such time and in such manner as to afford company and depository a reasonable opportunity to act on it.
Desired Withdrawal Date
Between the 1st and the 28th. To prevent delays in processing claims, select the same withdrawal date and initial effective date for the policy (i.e. Effective date is on the 1st, desired withdrawal date should be the 1st).
Bank Name
Bank City
Bank State
Type of Account

CheckingSavings
Account number:
If checking account, routing number (9 Digits)
Electronic Funds Transfer Signature

Clear
Date

MonthDayYear
Bill Me Directly

QuarterlySemi-AnnualAnnual
Is your billing address the same as your mailing address?

YesNo
Name of person paying, if different from applicant:
Billing Address
Street, City, State, Zip
EMAIL CONSENT AUTHORIZATION

ManhattanLife Assurance Company will provide important plan documents and printable cards via email. If you opt to decline email consent, paper copies will be sent via post and will take longer to recieve.
EMAIL CONSENT AUTHORIZATION

I give my written consent to allow the Missouri Optometric Association's Member Services and ManhattanLife Assurance Company to communicate with me by email to the addresses listed below. I confirm that I have authorization to provide consent for email to the email addresses that I provide below and further agree to indemnify and hold harmless the Company for any action or loss arising from any incorrect or false email addresses provided below. I acknowledge that, should I desire to revoke this written authorization, I will inform the Company in writing of such revocation.I decline to give consent to the Company to communicate with me by email. Do not provide email addresses below.
Primary email address:
example@example.com
Secondary email address (for recovery purposes only):
example@example.com
Email Consent Signature*

Clear
Note: The applicant electing to allow for notices and communications to be sent to the electronic mail address provided by the policyholder should be aware that the insurer rightfully considers this election to be consent by the applicant that all notices may be sent electronically, including notice of non- renewal and notice of cancellation. Therefore, the applicant should be diligent in updating the electronic mail address provided to the insurer in the event that the address should change.
INSURED’S AUTHORIZATION AND SIGNATURE

To the best of my knowledge and belief, all of the answers to the questions contained in this application are true and complete, and I understand and agree that: (a) the insurance shall not take effect unless and until the application has been accepted and approved by ManhattanLife Assurance Company of America (Company), the full first premium has been paid, and the policy has been delivered to the applicant; and, (b) oral statements between the agent and myself are not binding on the Company unless accepted by the Company in writing. I, the undersigned applicant, certify that I have read, or had read to me, the completed application and that I realize that any false statements or misrepresentations therein material to the risk may result in loss of coverage under the policy to which this application is a part. I have received the Outline of Coverage for the policy (in states required by law I further understand that within 60 days of the of the Company’s administrative office receipt of my application, I will be notified by the Company as to whether or not my application has been accepted, or the Company will give me a reason for any further delay. I further understand that within 60 days of the of the Company’s administrative office receipt of my application, I will be notified by the Company as to whether or not my application has been accepted, or the Company will give me a reason for any further delay.

CAUTION: If your answers on this application are incorrect and untrue, the Company may have the right to deny benefits or if the misrepresentation was material to our acceptance of the risk, rescind the policy.

NOTICE: ALL PREMIUM CHECKS MUST BE MADE PAYABLE TO MANHATTANLIFE ASSURANCE COMPANY OF AMERICA. DO NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK. THE EFFECTIVE DATE OF THE POLICY WILL BE THE DATE RECORDED BY THE ADMINISTRATIVE OFFICE. IT IS NOT THE DATE THIS APPLICATION IS SIGNED.
Signed at *
City, State
Signature - Print First, Middle Initial & Last Name*
Signature*

Clear
Year (last two digits of the year)
Eg. 2021, enter 21.
FRAUD WARNING:
Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of criminal offense under state law. I agree that no insurance shall be in effect until: (a) a policy has been issued; and (b) the first premium is paid while my insurability remains unchanged and then only if I am actually in the state of health represented in this application. I state that the answers set forth above, are full, complete and true to the best of my knowledge and belief. The answers are to be the basis of any insurance issued. I also acknowledge that I have received the Investigative Consumer Reports notification and MIB Notice attached to this application. All statements made by or on behalf of the insured or annuitant shall be deemed to be representations and not warranties.

By selecting submit, I hereby attest that I am purchasing this Dental, Vision, and Hearing policy as a supplement or in addition to other major medical health insurance coverage, also known as, "Minimum Essential Coverage."
Should be Empty:

APPLICANT INFORMATION

DEPENDENT(S) INFORMATION

GENERAL QUESTIONS

COVERAGE INFORMATION

BILLING

EMAIL CONSENT AUTHORIZATION