OR CALL 1-844-385-4359 Mon-Fri 8am-5pm CT
Illinois Retired Teachers Association
Illinois Retired Teachers Association

Dental & Vision Enrollment Form

Exclusively From AMBA & IRTA!


Tell Us About Yourself

  Are you a member of IRTA?


Not a member yet? No problem.
These plans are available to members of IRTA only so you will receive a call in the next 2-3 business days with instructions on becoming a member. You can also become a member by visiting www.irtaonline.org.

  Date of birth



Choose Your Coverage

Coverage Start Date

Coverage must start at the beginning of the month.

Dental Product

Rates good through Feb 28, 2023

Platinum Plan

Member Only: $66.33

Member + One: $132.67

Member + Family: $167.49

Plan Coverage »

Gold Plan

Member Only: $38.71

Member + One: $77.43

Member + Family: $97.75

Plan Coverage »

Select A Dental Plan
Select Number Of People Covered

Have you had dental coverage within the past 60 days?

Vision Product

Rates good through Feb 28, 2023

Member Only: $11.94

Member + One: $20.94

Member + Family: $26.04

Plan Details »

Select Number Of People Covered

Number of Dependents

Your spouse and dependent children up to the month they turn age 26 are eligible for coverage. Disabled dependent children 26 and older may be covered indefinitely.
A one time $20 application fee applies.


Billing Information

Authorization to honor drafts by the Association Members Benefits Advisors (AMBA).

NOTE: Bank drafts occur on the 2nd business day of each month.

Terms and Conditions

I understand that I am submitting an application for dental or vision insurance marketed by Association Members Benefits Advisors. Each application includes a one-time $20 application fee that is assessed on the same day as my first initial premium (void where prohibited). I understand that if I have any further questions I can reach AMBA at 1-844-385-4359. Should I decide to terminate my coverage during the first thirty days I am entitled to a refund of my premiums. I will return any claims paid during that time to the insurer. Terminations must be submitted in writing. I understand that by completing this form and clicking the submit button I am requesting coverage for the endorsed plans marketed through Association Members Benefits Advisors (AMBA).