AMBA Florida 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

? 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.

Mailing Address

Association

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

Payment Information

Pay Annually

Pay Monthly*

Initial Payment

Pay today - Become a Member today

Pay later - Choose my draft date

Recurring Payment

Choose recurring date

(2nd payment onwards)

Plan Price:	$24.17
Total due:	$24.17

Plan Price:	$290.00
Total due:	$290.00

Plan Price:	$32.50
Total due:	$32.50

Plan Price:	$390.00
Total due:	$390.00

*Monthly plan automatically renew each month, unless member cancels prior to the start of the next month.

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