AMBA MTS Lifetime Emergency Shield Plan Application

Names and Dates of Birth

Add Spouse Upgrade to Family

Add Dependent

Contact Information

Please provide at least one phone number.

Emergency Contact Information

Benefits Address

? The address where services will be rendered. Our Return and Recuperation benefits will bring you, your vehicle, your dependants, etc. to this address. This is usually your primary residence.

I want my mail to go to a different address ? If you do not plan to reside at your benefits address for a majority of the year, or if you would like to receive mail at a different address, please check this box.

** If a resident of Florida, Iowa, Kentucky, Pennsylvania, Wyoming, or West Virginia – Please call (866) 615-4075 to Enroll. MASA currently does not provide coverage to AMBA Associations for Alaska, New Jersey, District of Columbia, New York, North Dakota, and Washington.

Mailing Address

Association

Plan Fee:	$3,900.00
Total due:	$3,900.00

Plan Fee:	$4,900.00
Total due:	$4,900.00

Address 1
Address 2
City
State
Zip