an affordable solution to match your healthcare needs

PLATINUM SELECT TL

an affordable solutionaffordable solution to match your to match your healthcare needs

PLATINUM SELECT TL

HOSPITAL PATIENT ADVOCACY We work hard to lower your hospital bills!

ROADSIDE ASSISTANCE Keep your mind at ease and your caron the road!

PET CARE Protect that “other” family member, YOUR PET!

LEGAL SERVICES Legal advice at your fi ngertips!

WORLDWIDE $5,000 ACCIDENTAL INJURY You will be protected from virtually ANY injury!

WORLDWIDE $10,000 ACCIDENTAL DEATH & DISMEMBERMENT Protect your family from unexpected expenses!

$15,000 TERM LIFE / $15,000 ACCIDENTAL DEATH & DISMEMBERMENT Lessen the burden on yourloved ones!

WORLDWIDE EMERGENCY TRAVEL ASSISTANCE 100% coverage for worldwide air ambulance needs up to $100,000!

Platinum Select TL, providing you with affordable quality healthcare

Our mission has always been to provide our members with a SIMPLE-TO-USE and COST-EFFECTIVE association

group insurance, backed by the best customer service in the industry. That is why each of our plans has

been carefully created with select services and group benefi ts to offer you an exceptional healthcare

value at a reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with

PLATINUM SELECT TL:

HOSPITAL PATIENT ADVOCACY We work hard to lower your hospital bills!

ROADSIDE ASSISTANCE Keep your mind at ease and your caron the road!

PET CARE Protect that “other” family member, YOUR PET!

LEGAL SERVICES Legal advice at your fi ngertips!

WORLDWIDE $5,000 ACCIDENTAL INJURY You will be protected from virtually ANY injury!ANY injury!ANY

WORLDWIDE $10,000 ACCIDENTAL DEATH & DISMEMBERMENT Protect your family from unexpected expenses!

$15,000 TERM LIFE / $15,000 ACCIDENTAL DEATH & DISMEMBERMENT Lessen the burden on yourloved ones!

WORLDWIDE EMERGENCY TRAVEL ASSISTANCE 100% coverage for worldwide air ambulance needs up to $100,000!

Platinum Select TL, providing you providing you with affordable quality healthcare with affordable quality healthcare

Our mission has always been to provide our members with a SIMPLE-TO-USE and SIMPLE-TO-USE and SIMPLE-TO-USE COST-EFFECTIVE association

group insurance, backed by the best customer service in the industry. That is why each of our plans has

been carefully created with select services and group benefi ts to offer you an exceptional healthcare

value at a reasonable cost. Sign up today and enjoy the healthcare solution you’ve been looking for with

PLATINUM SELECT TL:

AWIS032_PLATIN

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SELECTTL_PITCH

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REV:01.11.2011

10878 Westheimer Rd., Suite # 191, Houston, TX 77042 Phone: 1.866.365.5829 Fax: 1.866.837.4556

AWIS032_PlAtInumSelec t tl_APP Re v:08.23.2011

MEMBER INFORMATION (PLEASE PRINT CLEARLY)

Last Name: First Name: M.I. D.O.B:

Mailing Address:

Apt #: City: State: Zip:

Gender: Language:

E-mail: Home Phone #:

Cell Phone #: Work Phone #:

Fax #: Beneficiary:

MEMBER'S FAMILY INFORMATION (PLEASE PRINT CLEARLY)

Spouse’s First Name: Last Name: D.O.B:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship:

Dependent’s First Name: Last Name: D.O.B: Relationship: (For additional dependents, add additional sheets)

BILLING INFORMATION (PLEASE SELECT ONLY ONE METHOD OF PAYMENT)

One-Time Application Fee: $ Monthly Dues: $ Total: $

Bank Draft or Debit: (check only one) Checking Savings

Name of Account Holder: Bank Name:

Bank Transit #: Bank Account #:

Credit Card: (check only one) VISA American Express Discover MasterCard

Name of Account Holder:

Account #: Expiration Date: CVV2 #: (The CVV2 # is the last 3 digits next to the signature line on the back of your credit card; or the 4 digits after your account # for American Express)

I have read the terms, conditions, and disclosures on the back of this application and authorize American Workers Insurance Services or its designated attorney-in-fact to electronically draft my account or bill my credit card indicated on this application for my one-time initial application fee and my membership recurring dues. I understand I am eligible for a refund of my membership dues if I cancel in writing by fax or mail within 30 days from postmark on my membership packet plus five (5) days.

� Check this box if you are paying for this membership and are not the member.

X Date: Signature of the Depositor or Credit Card Holder (Must be signed by employer if employer is paying the membership dues.)

SPONSOR & ENROLLER INFORMATION

Sponsor Name:

IMA/MSA #:

Enroller Name:

IMA/MSA #:

Date:

FOR OFFICE USE ONLY

2 3 4 5 6 7

MEMBER APPLICATIONPLATINUM SELECT TL

PLAN SERVICES

•  Individual Monthly Dues: $69.95

•  Family Monthly Dues: $79.95

•  One-Time Application Fee: $100

Fees and Dues: •   Hospital Patient Advocacy•   Roadside Assistance•   Pet Care•   Legal Services•   $5K Accidental Injury*

•   $10K Accidental Death & Dismemberment *

•   $15K Term Life Insurance/ $15K Accidental Death & Dismemberment †

•   Emergency Travel Assistance ‡

Please fax application to: 1.866.837.4556; or mail to: American Workers Insurance Services, 10878 Westheimer Rd., Suite # 191, Houston, TX 77042

AGREEMENT OF TERMS & CONDITIONS (PLEASE PRINT CLEARLY)

I, the customer, understand that I am joining American Workers Insurance Services (AWIS) as Platinum Select TL member. I further understand that by joining the Platinum Select TL program, I will automatically become a member of the National Association of Preferred Providers (NAPP). As a member of the NAPP association and at no additional cost to me, I am entitled to limited association group insurance benefits after a waiting period; for specific benefit waiting periods, call Member Services at 1.866.365.5829. These limited association group insurance benefits are not comprehensive health insurance.

I understand that I have purchased a membership in AWIS from , IMA/MSA # .

I have read and understand the cancellation policy and disclosures set forth below.

X Date: Signature

PROGRAM DISCLOSURES

The program‘s services and group benefits are marketed by American Workers Insurance Services (AWIS), a licensed insurance agency. Not available in AK, CO, CT, GA, GU, MA, MD, ME, MN, MT, ND, NE, NY, OK, PR, SD, VI, and VT.

Cancellation Policy

American Workers Insurance Services membership renews automatically by continuing the payment of the monthly membership dues. There is no renewal fee. In addition to paying monthly, the membership dues can be paid quarterly, semi-annually, or annually. If the member wishes to change their billing cycle, they should contact American Workers Insurance Services at 1.866.365.5829. American Workers Insurance Services members may cancel their membership in writing without giving a reason during the first thirty (30)§ days from the date of the postmark on the member fulfillment package, plus five (5) days, and will

receive a refund of membership dues paid. The one-time enrollment fee is held as a non-refundable processing fee¶. The cancellation effective date shall be the date of the postmark if sent by mail and the business day of receipt if sent by facsimile transmission. Members should allow three (3) to four (4) weeks for their refund. Members may cancel their membership at any time after the first thirty (30)§ days, provided American Workers Insurance Services is given a written notice of cancellation. Membership package and cards must be returned upon cancellation. It may take up to fourteen (14) to thirty (30) days after receiving a valid cancellation request for collection of dues to stop.

§ Forty-five (45) days in California.

¶ Fully refundable in Tennessee. $30 of the enrollment fee will be non-refundable in CA, IL, IN, LA, SC, and TX.

LIMITED ASSOCIATION GROUP INSURANCE BENEFITS DISCLOSURES

* $5K Accidental Injury and $10K Accidental Death & Dismemberment: Association group insurance benefits provided through a blanket special risk insurance policy (GA 26932-003) issued and underwritten by United States Fire Insurance Company.

† $15K Term Life Insurance / $15K Accidental Death & Dismemberment: Association group insurance benefits provided through an insurance policy (67432) issued and underwritten by ReliaStar Life Insurance Company.

‡ Emergency Travel Assistance: Association group insurance benefit provided through an Agreement with the Lifeguard Emergency Travel Corporation and a group insurance policy (RNMWC1003634) issued and underwritten by Lloyd's of London.