Enroll/renew

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Would you like to apply by mail?
Please use this PDF ENROLLMENT FORM to apply using a check or money order.

 

MEMBER INFORMATION:

First Name

M.I.

Last Name

Address (1)

Address (2)

City

State

Zip

Home Phone

Work Phone

Mobile Phone

Birth Date

//

Sex

Marital Status

Employer

Email

   
Dependent Information
(List spouse or civil union partner and unmarried dependent children under age 25 that you wish to enroll.)

Dependent #1

First Name

M.I.

Last Name

Birth Date

//

Sex

Relationship

 

Dependent #2

First Name

M.I.

Last Name

Birth Date

//

Sex

Relationship

 

Dependent #3

First Name

M.I.

Last Name

Birth Date

//

Sex

Relationship

 

Dependent #4

First Name

M.I.

Last Name

Birth Date

//

Sex

Relationship

 
ANNUAL MEMBERSHIP FEES:

Plan Level

Member only: $49.00
Member plus one dependent: $98.00
Member plus two or more dependents: $149.00

   
PAYMENT METHOD

 

Visa
American Express
MasterCard
Discover

Questions or Comments

   
I agree to the terms and conditions (displayed below)
   
 

terms & conditions

  • Dental plan will become effective on the first day of the month in which membership is paid.
  • Membership is for a period of one year from the effective date.
  • You must be treated by a participating provider to be eligible for discount.
  • Any procedure not listed is discounted at 30% off provider’s then current fees.
  • All applicants must be 18 years or older.
  • Eligible dependents include your spouse or civil union partner and unmarried dependent children under age 25.
  • Ortho treatment: patient must remain a member of the plan for the duration of treatment or risk additional charges.
  • This program cannot be used with any other insurance or benefit coverage.
  • This is not dental insurance.