Catastrophic Major Medical Plan Dependent Coverage Form
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1AMA-sponsored Catastrophic Major Medical Plan
Dependent Coverage Form
Certificate Owner (Primary Insured) Information:
Name: ___________________________________________________
Address: _________________________________________________
City: ________________ State__________ ZIP _________________
Email: _______________________________________
May AMA Insurance email you regarding products and services? [ ] YES
Certificate Number (if known): _______________________________
If no dependents are currently insured, change my insurance to [ ] Physician + 1 [ ] Physician + Family
I would like to add the following dependent(s) to my coverage:
[ ] Male
________________________________ _______________________ _________________
[ ] Female
Dependent Name
Date of Birth
Relationship
[ ] Male
________________________________ _______________________ _________________
[ ] Female
Dependent Name
Date of Birth
Relationship
[ ] Male
________________________________ _______________________ _________________
[ ] Female
Dependent Name
Date of Birth
Relationship
[ ] Male
_______________________________ _______________________ _________________
[ ] Female
Dependent Name
Date of Birth
Relationship
If you have additional dependents, please attach a separate sheet.
I affirm that any dependents I have enrolled are under age 30 and currently insured under my Basic Plan. I
understand that this plan will not cover pre-existing conditions for an injury or sickness diagnosed or
undiagnosed for which medical care has been received by my dependents within 6 months prior to the
effective date of the dependent’s coverage, for 12 months following the date the effective date of the
dependent’s coverage or the dependent stays insured for 12 continuous months. Important Notice: Any
person who knowingly and with intent to defraud any insurance company or other person files a 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 may be a
crime. (Fraud language varies by state.)
__________________________________________
_________________
Signature of Primary Insured
Date
Policy No. #E-164,874
Sponsored by:
American Medical Association
Administered by:
AMA Insurance Agency, Inc.,
Underwritten by:
The United States Life Insurance Company in the City of New York
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Parent category: Medical