POSCard Fax/Mail Application Form
If paid by check (mail only), the monthly premium mode will be automatic bank draft only.
Please Complete and Fax to: 847-483-9485, or, Mail to the address shown below
First Name
Last Name
Mailing (Billing) Address:
City:
Zip:
Your Social Security #
Your Date of Birth
Phone # (include area code):
E-Mail Address:

Family Information
First Name
Last Name
Date of Birth
Spouse
1st Child
2nd Child
3rd Child
4th Child
5th Child

PAYMENT INFORMATION
Card Type
Card Number:
Expiration Date:
Credit Card Holder Name
Exactly as it appears on the Credit Card
Select Membership and Premium Mode
 ADD $15 ONE TIME ENROLLMENT FEE TO
PREMIUMS SHOWN IN BOX AT RIGHT
Please tell us how you found our web site
Please give us the name of the source
Search engine name, magazine, link site, etc.

AGREEMENT DISCLOSURE
Terms and Conditions

You may use the dental, vision and chiropractic referral services according to the Member Information Guide and Membership Identification Card(s).

Your request for coverage authorizes Discount Services, Inc. to charge your credit card for the initial payment to start your membership in POScard program. Discount Services, Inc. will then charge your credit card each month. You must provide Discount Services, Inc. 30 days written notice if you wish to cancel this dental membership.

ENROLLMENT FEE
A one time, non-recurring enrollment fee of $15.00 will be added to the first modal premium charge that appears on your credit card statement. Your TOTAL INITIAL PAYMENT CHARGE will be your chosen plan premium PLUS $15.00. All premiums thereafter will be the chosen modal premium.

EFFECTIVE DATE
 I understand that my coverage will not become effective, active and available until the 1st day of the 1st month following submission of my application unless the "Earliest Available" option was chosen on the application.

I understand that if I have chosen the "Earliest Available" option, my plan benefits will become available to me 2 business days after receipt of my application by Discount Services, Inc., that my credit card will be billed for a full month regardless of the number of days remaining in the month at the time benefits become available, and that I am not eligible for any benefits, retroactive or otherwise, prior to the actual activation date, regardless of the effective date used for billing purposes.


AGREEMENT AND AUTHORIZATION

I/We have read, understand and agree to the terms and conditions above. I authorize Discount Services, Inc. the authority to charge my credit card for all future renewal premiums as they come due. I will notify Discount Services, Inc. in writing of my wish to cancel the membership 30 days in advance.

I/We have read, understand and agree to the terms and conditions above. I/We hereby request and authorize you to pay checks drawn on my account by Discount Services, Inc, and payable to same provided there are sufficient collected funds in said account to pay the same upon presentation. This authorization is to remain in effect until Discount Services, Inc receives written notification from me revoking the authorization

Plan exclusions: (1) Work in progress is not covered. (2) Work in progress after enrollment on the dental plan must be completed before selecting another participating dentist. (3) Any dental procedures performed by a non-participating dentist are not covered. (4) Careington International cannot guarantee the continued participation of any dentist. If he/she leaves the plan, you will need to select another dentist. (5) Not all types of dentists may be available in your area; you may have to travel to receive care from a participating general dentist or specialist. (6) Some providers may charge if you miss or break appointments without prior notice. (7) Please verify that the dentist is a participating provider when scheduling your appointment.

If you agree to these terms and conditions, please print out this form by clicking on your "Print" icon.
Sign and date the form and Fax both pages to 847-483-9485.
Please keep the original for your records.





Authorized Signature: _____________________________________ Date: _________________

If you prefer to mail the form, please send it to:

Comprehensive Insurance
3601 Algonquin Rd.
Suite 850
Rolling Meadows, IL 60008

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