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Individual Disability Income

Family Accident Policy 10,000 Application

Applicant Information

First Name:

Last Name:






Name Relationship Age

Effective Date:

Payment Information

Account Type:

Checking Savings

Routing Number:

Account Number:


$435.95 Yearly $40 Monthly

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.


All 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 Authorization

I 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.