Application & Payroll Deduction Forms

Dental, Vision, & Insurance Benefits

Application & Payroll Deduction Forms

Federal & Postal Deduction Forms

1199s with application

You may submit your application online below or mail it.

You may speed up the process by enrolling online, downloading the

allotment form, and starting your payroll deduction online by using.

Employee Express, or National Finance Center, or PostalEASE

Please return a copy of the allotment form to our administrator.

American Marketing Administrators, Inc.

Insurance Agency & Registered Insurance Administrator

23901 Calabasas Road Suite 2014

Calabasas, CA 91302-3307

818-223-9750, Fax 818-223-9651, 800-300-PLAN

Email Questions

1199 for Federal Employees application

1199 for Postal Employees & application

Online Application click submit below when finished.

Dental HMO & VisionCare subscribers only.

Name: Last, First, Mi as it appears on your pay check
Social Security Number
Employer
Location ie TSA Miami, USPO Houston, Customs D.C.
Home Street
Home City
Home State
Home ZIP CODE
Home Zip + 4 if you know it
Home Area Code
Home Phone
Home Fax
Email Personal (only used for this purpose-not sold to anyone
Work Street
Work City
Work State
Work Zip + 4 if you know it
Work Phone Area Code
Work Phone
Work Fax
Work Email (only used for this purpose-never sold)
Date of Birth (example 07/11/1979)
Spouse Name
Spouse Date of Birth (09/25/1980
Name Child(ren) & Date of Birth
Dental Plan (ie 550V, 13V, ANTX, 110, 250, HO, SO, PPO)
DENTAL HMO Their DDS #
For HMOs only> Name, Date of Birth, Social Security # of Additional people and relationship to add to your plan for the premium of a single adult (ie Over Age Child(ren), Grand Child(ren), Parent(s), Domestic Partner, Sibling(s), other)
Their Relationship
Are you interested in receiving information on additional insurance	yes
	no
Disability Insurance	yes
Disability Insurance	no
Cancer additional benefit	yes
Cancer additional benefit	no
Medical Insurance for a non-federal or non-postal employee	yes
Medical Insurance for a non-federal or non-postal employee	no
Person Needing Medical Insurance or Medical HMO > Name, date of birth, zip code

Email Questions

American Marketing Administrators, Inc.

Insurance Agency & Registered Insurance Administrator

23901 Calabasas Road Suite 2014

Calabasas, CA 91302-3307

818-223-9750, Fax 818-223-9651, 800-300-PLAN