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ENROLLMENT FORM
Information About You

LAST NAME FIRST NAME GENDER DATE
OF
BIRTH 		 MO DAY YR PHONE

Male   Female   		/ /
HOME ADDRESS - STREET CITY STATE ZIP
EMPLOYER NAME AND LOCATION (CITY & STATE) DATE
OF
HIRE 		 MO DAY YR
/ /
ASSOCIATION THAT YOU BELONG TO: (CHOOSE ONE)

  State Bar of Wisconsin
 Wisconsin Institute of CPAs
 Greater Milwaukee Association of REALTORS
 Wisconsin Funeral Directors Association
 		  YOUR ASSOCIATION MEMBERSHIP NUMBER

   

Information About Your Dependents

    GENDER DATE OF BIRTH
LAST NAME (IF DIFFERENT) FIRST M/F MO DAY YR
SPOUSE/DOMESTIC PARTNER          
OTHER DEPENDENTS          
           
           
           
           

Select Program(s)

Choose up to four discount programs:
Vision
Dental
Pharmacy
Chiropractic
Hearing
 

  Monthly Rates for PIP — Affiliated Plans:
  Any one plan:    $8.50 per head of household  
  Any two plans:    $9.00 per head of household  
  Any three plans:    $9.50 per head of household  
  Any four plans:    $10.00 per head of household  
 


Verify Network Accessibility

For any discount program that you have selected, please check this box to verify that you have confirmed that Benessential network providers are accessible in your area.

Choose Payment Method

Credit Card:
 Visa
 Mastercard
 American Express
 Discover
Payment Frequency:    Monthly    Annually  

Credit Card Payment Agreement: If payment is to be made by a credit card, please complete the following information.

Credit card number:

Exp. date:

Name on card:

I hereby authorize Wyssta Services, Inc., to charge my credit card account as indicated above, based on plan, coverage type and payment plan I have chosen, until I elect to cancel. 		  Electronic Funds Transfer from your savings or checking account

ACH Financing Agreement: If payment is to be made through electronic funds transfer, please complete the following information.

Depository Name:

Depository transit ABA number:

Account number:

Account type: Savings  Checking 

Payment frequency: Monthly   Annually  

I hereby authorize Wyssta Services, Inc., to initiate debit entries and to initiate, if necessary credit entries and adjustment for any debit entries in error to my account and the financial institution indicated above, herein called Depository, to debit and/or credit the same such account. This authority is to remain in full force and effect until Wyssta has recieved written notification from me of its termination in such time and in such manner as to afford Wyssta and Depository a reasonable opportunity to act on it.

Program Agreement

The Benessential Discount Card Program, (the "Program") in this application is not insurance and is not intended to replace any existing insurance you may have. This Program does not make payments directly to providers. As a Program member, you are obligated to pay the providers in the network for any services received. Payment for services is based upon a pre-negotiated discount fee with providers and the discount is available only for providers in the network.

Acceptance

By accepting this Program, I am confirming that I am at least 18 years of age; that I have reviewed and understand all the Program information provided herein; I agree to the Program terms and conditions; and further agree to permit Wyssta Services, Inc. to charge my credit card or withdraw funds electronically, as I have indicated above, for the purpose of payment at the rate for the plan(s) I have chosen.

 I Agree.  
 I Do Not Agree. If you choose this option, this application immediately becomes null and void.  
 
 
Print Name (as it appears on credit card or bank account)      Date

The Benessential Discount Card Program is administered by Wyssta Services, Inc., a wholly-owned subsidary of Delta Dental of Wisconsin, Inc. using networks administrated by American Dental Professional Services, LLC., Innoviant, and EyeMed Vision Care, LLC.


For additional information, call 866-539-1068