AMBA Platinum 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

?
I want my mail to go to a different address ?
** 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.

Association

I have read and agree to the Disclaimers and terms and conditions in the Member Service Agreement/Policy

Payment Information

Pay Annually
Auto-renew my Plan each year
Pay Monthly*
Initial Payment
Pay today - Join Today
Pay later - Choose my draft date

Recurring Payment
Choose recurring date
(2nd payment onwards)

Plan Price: $27.00
Total due: $27.00
Plan Price: $324.00
Total due: $324.00
Plan Price: $35.00
Total due: $35.00
Plan Price: $420.00
Total due: $420.00
*Monthly plan automatically renew each month, unless applicant cancels prior to the start of the next month.
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