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

The policy provides limited benefits. Review your policy 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. Underwritten by Ameritas Life Insurance Corp. | 5900 O Street Lincoln, NE 68510 This is not a certificate of insurance or guarantee of coverage. Plan designs may not be available in all areas and are subject to individual state regulations. This piece is not for use in New Mexico. This information is provided by Ameritas Life Insurance Corp. (Ameritas Life). Dental, vision and hearing care products (9000 Rev. 03-16 for Group and 9000 Rev. 10-22 for Individual, dates may vary by state) are issued by Ameritas Life. The Dental and Vision Networks are not available in RI. In Texas, our dental network and plans are referred to as the Ameritas Dental Network.

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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