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I authorize Ameritas Life Insurance Corp. to initiate electronic debit entries to my account chosen above for payment of my insurance premium. I certify that I am an authorized user on the above listed account. I acknowledge that debits to my account for premium due will occur on a regular recurring basis based on the payment frequency indicated above until such time as coverage terminates or until I notify Ameritas to terminate these transactions. I understand that it may take up to two weeks to process a request to discontinue recurring payments. In order to make changes to this authorization (such as change in bank account, method of payment, or termination of payment) I must provide Ameritas at least two weeks notice in advance of the next scheduled payment date.

Payment Information:

1. Initial premium will be withdrawn within 3 days of your policies effective date, subsequent premiums are due on the day of the month in which the policy was effective.

2. For initial payments I acknowledge that Ameritas may debit my account upon acceptance and approval of my application. Based upon my authorization, Ameritas will process reoccurring payments on or within three business days of the date of the month in which my policy was first effective.

For initial payments I acknowledge that Ameritas may debit my account upon acceptance and approval of my application. Based upon my authorization, Ameritas will process reoccurring payments on or within three business days of the date of the month in which my policy was first effective.

If any authorized payment is returned or dishonored by my bank, I acknowledge that I am responsible for any fees my bank may charge. I understand also that I may incur a return payment fee of $25 charged by Ameritas if the return is due to insufficient funds. I acknowledge that such a fee, if charged, may be automatically debited from my authorized account on the next payment date. I am responsible for remitting payment within the policy grace period. If payment is not received by Ameritas within the defined grace period I acknowledge that my coverage may be cancelled in accordance with the terms of the insurance contract.

I also acknowledge that I have read the following information from Ameritas regarding this electronic signature.

I consent to receiving my Outline of Coverage where applicable, and any other plan information electronically and I electronically affirm of my consent to do so. I understand I need internet access and that I can withdraw my consent at any time per the notification instructions below, I understand I can receive any of the documents in paper form if I choose.

    - I may return my policy within the right-to-cancel period as described in my policy;

    - I acknowledge receipt of the Outline of Coverage (in states where required by law);

    - I understand the policy I am applying for provides dental and (if chosen) vision benefits only and is not a Medicare supplement;

    - I acknowledge that the agent of record, if applicable, is my insurance agent for purposes of the Ameritas Privacy Policy; and

    - I understand that it is my responsibility to give notice to Ameritas of changes in my email address or any information above, as well as my status and my family's status that effect coverage, such as marriage, births, or death of someone covered under the policy. I will provide notice via email at [email protected], fax at 402-309-2598 or in writing to Ameritas or its designee: PO Box 82607, Lincoln, NE 68501-2607.

You are encouraged to print a copy of your electronic forms to retain for your own records. The computer hardware and software necessary to access your electronic forms are a personal computer with a Windows or Macintosh operating system. You will be notified by mail if there is ever a change in the hardware or software requirements for accessing your electronic forms.

DENTAL LIMITATIONS & EXCLUSIONS

What is not covered:
Covered expenses will not include and benefits will not be payable for expenses incurred:
• for any treatment which is for cosmetic purposes.
• to replace any crowns, inlays, onlays, veneers, complete or partial dentures within five years of the date of the last placement of these items. But if a replacement is required because of an accidental bodily injury sustained while the Insured person is covered under this contract, it will be a covered expense.
• for initial placement of any dental prosthesis or prosthetic crown unless such placement is needed because of the extraction of one or more teeth while the insured person is covered under this contract. But the extraction of a third molar (wisdom tooth) will not qualify under the above. Any such appliance or fixed partial denture must include the replacement of the extracted tooth or teeth.
• for any procedure begun before the insured person was covered under the policy.
• for any procedure begun after the insured person’s insurance under the policy terminates; or for any prosthetic dental appliances installed or delivered more than 90 days after the insured’s insurance under the policy terminates.
• to replace lost or stolen appliances.
• for appliances, restorations, or procedures to:
– alter vertical dimension;
– restore or maintain occlusion; or
– splint or replace tooth structure lost as a result of abrasion or attrition.
• for any procedure which is not shown on the Table of Dental Procedures. (There may be additional frequencies and limitations that apply, please see the Table of Dental Procedures in the policy.)
• for orthodontic treatment under the Advantage Plus plan the following provisions:
– for treatment begun on or after the insured’s 19th birthday;
– for treatment begun before the insured became covered under this section;
• for which the insured person is entitled to benefits under any workmen’s compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit (except in CA & KY).
• for charges for which the insured person is not liable or which would not have been made had no insurance been in force.
• for services which are not required for necessary care and treatment or are not within the generally accepted parameters of care.
• because of war or any act of war, declared or not.
• if two or more procedures are considered adequate and appropriate treatment to correct a certain condition under generally accepted standards of dental care, the amount of the covered expense will be equal to the charge for the least expensive procedure.

VISION LIMITATIONS & EXCLUSIONS

What is not covered:
Based on applicable laws, reduced costs may vary by doctor locations. Covered expenses will not include and no benefits will be payable for:
• Vision examinations, lenses and frames more than the frequency as indicated on the plan summary page.
• Orthoptics or vision training and any associated supplemental testing.
• Plano lenses (lenses with refractive correction of less than plus or minus .50 diopter) except as specifically allowed in the frames benefit section of the Plan Benefits.
• Two pairs of glasses in lieu of bifocals.
• Replacement of spectacle lenses, frames, and/or contact lenses furnished under this plan that are lost or damaged, except at the normal intervals when services are otherwise available.
• Medical or surgical treatment of the eyes.
• A service which is not listed under the Schedule of Eye Care Services found in the certificate. Members pay costs exceeding plan benefits.

Review your policy carefully

In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements below.)

Note for California Residents: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

For policies issued, amended, delivered, or renewed in California, dependent coverage includes individuals who are registered domestic partners and their dependents.

No Cost Language Services. You can get an interpreter and have documents read to you in your language. For help, call us at the number listed on your ID card or 877-233-3797. For more help call the CA Dept. of Insurance at 800-927-4357.

Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al número que fi gura en su tarjeta de identifi cación o al 877-233-2797. Para obtener más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.

Note for Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Note for D.C. Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Note for Florida Residents: 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.

Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law.

Note for Kentucky Residents: 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 commits a fraudulent insurance act, which is a crime.

Note for Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Note for New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Note for New Mexico and Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

Note for New York

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five‑thousand dollars and the stated value of the claim for each such violation.

Note for North Carolina Residents: After 2 years from the date of issue or reinstatement of this policy, no misstatements made by the applicant in the application shall be used to void the policy or deny a claim for loss commencing after the expiration of such 2 year period.

Pursuant to NCGS 58-2-161(b), any person who knowingly and with the intent to injure, defraud, or deceive an insurer or insurance claimant is guilty of a crime (Class H felony) which may subject the person to criminal and civil penalties.

Note for Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Note for Texas Residents: Any person who knowingly and with intent to defraud provides false, incomplete or misleading information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, may be guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim.

Note for Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of coverage.