MEDI-EMERGENCY HEALTH PLAN
ENROLLMENT
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HEALTH PLAN MEMBERSHIP SIGN-UP

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.......EMPLOYEE HEALTH PLAN
MEMBERSHIP PAYMENT AGREEMENT

We do hereby accept and agree to the terms and conditions as set forth under this AMERICAN EMPLOYEES ASSOCIATION Voluntary Employees’ Beneficiary Association (VEBA) General Association Membership agreement and authorize the AMERICAN EMPLOYEES ASSOCIATION to automatically charge/draft my membership contributions by Electronic Funds Transfer (EFT) from my bank or financial institution, credit or debit card, checking and/or savings accounts. This authority is to remain in effect until AMERICAN EMPLOYEES ASSOCIATION receives written notification from me revoking the authorization and membership. Our account will be drafted each month on or about the effective date of my membership not to exceed the amount stated and agreed to above.

YO, por este medio, acepto y estoy de acuerdo con los términos y condiciones estipulados bajo este acuerdo (ACUERDO GENERAL DE MEMBRESIA DE LA ASOCIACION VEBA (Asociación voluntaria de empleados benficiarios) y autorizo a LA ASOCIACION AMERICANA DE EMPLEADOS (AMERICAN EMPLOYEES ASSOCIATION) a debitar/retirar automáticamente mis pagos de membresía por medio de Transferencia de Fondos Electrónica (EFT) de mi banco o institución financiera, tarjeta débito or crédito, cuenta de cheques (checking) y/o cuenta de ahorros (savings). Esta autorización permanecerá en efecto hasta que LA ASOCIACION AMERICANA DE EMPLEADOS (AMERICAN EMPLOYEES ASSOCIATION) reciba notificación escrita de mi parte revocando esta autorización y membresía. Mi cuenta será debitada cada mes, en o hacia la misma fecha en que se hizo efectiva mi membresía sin exceder la cantidad establecida y acordada arriba. YO, confirmo que soy el único responsable de pagar cualquier cargo/fee relacionado a mis transacciones EFT. YO, declaro, bajo penalidad por perjurio de membresía y beneficios que soy elegible bajo las reglas gobernantes de la organización y que la información presentada aquí es verdadera y correcta.

I hereby acknowledge, understand and accept the association membership and pre-paid health plan fee schedule(s) and agree to pay in full all annual association and health plan contributions, trust, administration as well as any and all other applicable fees prior to commencement of any benefits under the terms and conditions of this agreement.

YO, por este medio, recibo, entiendo, acepto y estoy de acuerdo con los cargos/fees programados y me comprometo a pagar en su totalidad las contribuciones anuales acordadas, fondos fiduciarios y administración así como otros cargos/fees por servicio antes del inicio de cualquier beneficio bajo los términos y condiciones de este acuerdo.

I ALSO UNDERSTAND, ACCEPT AND AGREE THAT MEMBERSHIP BENEFITS UNDER THIS PROGRAM WILL NOT BECOME EFFECTIVE UNTIL PAYMENT IN FULL OF ALL REQUIRED FEES AND CONTRIBUTIONS.

YO, ENTIENDO, ACEPTO Y ESTOY DE ACUERDO CON QUE LOS BENEFICIOS DE MEMBRESÍA BAJO ESTE PROGRAMA NO SE HARÁN EFECTIVOS HASTA QUE SE PAGUEN EN SU TOTALIDAD TODOS LOS CARGOS/FEES REQUERIDOS Y CONTRIBUCIONES ACORDADAS.

I UNDERSTAND, ACCEPT AND AGREE TO DOWNLOAD, COMPLETE SIGN AND RETURN TWO (2) COPIES WITH ORIGINAL SIGNATURES OF EACH REQUIRED DOCUMENT WITHIN 10 DAYS TO THE AEA ADMINISTRATION OFFICE AT THE ADDRESS LISTED BELOW IN ORDER TO PROPERLY COMPLETE YOUR HEALTH PLAN ENROLLMENT AND FORMAL ACTIVATION OF COVERAGE.

Administration Department
AMERICAN EMPLOYEES ASSOCIATION
6655 West Sahara Avenue, Suite B-200
Las Vegas, Nevada 89146

I confirm that we are solely responsible for paying any bank or financial institution fees related to our EFT transactions. I declare under penalty of forfeit of membership and benefits that I am eligible under the governing rules of the organization and the information submitted herein is true and correct.

By clicking on the payment button, I confirm I have read, accept and agree to the terms and conditions setforth under this agreement.

If you need assistance signing up, call 877.863-6756 (877.UNEMPLOYED) or e-mail: administrator@americanamployeesassociation.com.

** Please note that Spanish translations are provided for user convenience ONLY!! ENGLISH directives and statements shall control in any and all cases of discrepancies.

** Por favor tenga en cuenta que la traducción al español se ofrece UNICAMENTE para la conveniencia del usuario. Las directivas y texto en INGLES prevalecerán en caso de cualquier discrepancia.
Employee Health Plan Enrollment

SINGLE PAYMENT

[1] AEA-EPM-SP-106

$ 120.00 - Membership (Waived)
$ ..05.00 - Processing (Waived)
$ 365.00 - Health Plan Fee
$ 365.00 - SINGLE PYMT/YR


Employee Health Plan Enrollment

MONTHLY PAYMENT

[2] AEA-EPM-RP-115

TOTAL MONTHLY PYMTS- (1st Month)
$ ..10.00 - Membership (Waived)
$ x30.42 - Per Month
$+ 00.30 - Finance (1%)
$ .. 30.72
$+_ 05.00 - Processing
$ ...35.72 - TOTAL DUE (1st Month**)

TOTAL MONTHLY PYMTS- (1st Year)
$ ..120.00 - Membership (Waived)
$+ 035.72 - 1st payment **
$+_392.92 - (11 x $35.72)
$ ..428.64 - TOTAL PYMTS (1st Year)


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Cancellation
Click on the button below to cancel your Health Plan membership payment agreement at anytime.