By using this site, you agree to the Privacy Policy, Terms of Use and HIPAA Privacy Notice.

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.
PrevNext
April 2025
SuMoTuWeThFrSa
  12345
6789101112
13141516171819
20212223242526
27282930