| Effective Date
All 
                                                applications will be come effective 
                                                on the first of the month following 
                                                receipt of the application by 
                                                ABA. This website is a summary 
                                                of coverage, please review your 
                                                certificate for additional details. EligibilityAll 
                                                dues paying members under age 
                                                70, and family (lawful spouses, 
                                                under age 70, and dependent children, 
                                                under age 18, living at home). 
                                                All eligible applicants accepted. Check-O-Matic AuthorizationI 
                                                authorize American Benefits Association 
                                                or its designated agent to electronically 
                                                draft my account for my annual 
                                                membership fee. The name of my 
                                                bank is listed above for my monthly 
                                                membership fee. I instruct my 
                                                bank, as identified below, to 
                                                honor checks drawn in the name 
                                                of American Benefits Association 
                                                or its designated agent acting 
                                                as the Association's agent-in-fact 
                                                as a convenience to me to charge 
                                                my account and to pay the Association's 
                                                account the amount stated in the 
                                                electronic transfer. This authorization 
                                                is to remain in effect until revoked 
                                                by me in writing and you, my bank, 
                                                shall be fully protected in honoring 
                                                any such check or electronic debit. 
                                                I agree that if your treatment 
                                                of each check or electronic debit 
                                                is dishonored, whether with or 
                                                without cause, the bank shall 
                                                be under no liability. I have 
                                                agreed to have American Benefits 
                                                Association or its designated 
                                                agent safeguard this authorization, 
                                                along with my voided check, to 
                                                you, the bank I have named below. 
                                                I understand that if for any reason 
                                                a scheduled transfer is rejected 
                                                by my bank an additional $5.00 
                                                charge will apply. 
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