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Member Information
First Name:
Middle Initial:
Last Name:
Address (1):
Address (2):
City:
State:	ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
Zip:
Home Phone:
Work Phone:
Mobile Phone:
Birth Date:
Sex:	MaleFemale
Marital Status:	SingleMarriedDivorced
Employer:
Email:
Dependent Information (List spouse or civil union partner and unmarried dependent children under age 26 that you wish to enroll.)
Dependent #1
First Name:
Middle Initial:
Last Name:
Birth Date:
Sex:	MaleFemale
Relationship:	SpouseCivil Union PartnerUnmarried Dependent Child Under 26
Dependent #2
First Name:
Middle Initial:
Last Name:
Birth Date:
Sex:	MaleFemale
Relationship:	SpouseCivil Union PartnerUnmarried Dependent Child Under 26
Dependent #3
First Name:
Middle Initial:
Last Name:
Birth Date:
Sex:	MaleFemale
Relationship:	SpouseCivil Union PartnerUnmarried Dependent Child Under 26
Dependent #4
First Name:
Middle Initial:
Last Name:
Birth Date:
Sex:	MaleFemale
Relationship:	SpouseCivil Union PartnerUnmarried Dependent Child Under 26
Annual Membership Fees
Plan Level:	Member Only: $99.00  Family (4 or more): $340.00
Payment Method:	VisaMasterCardAmerican ExpressDiscover
Number:
Expiration:	123456789101112 / 202320242025202620272028
Code (CSV):
Questions or Comments:
Promo Code:
	I agree to the terms and conditions  (displayed below)
Required

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 that cannot be performed by a participating provider is not covered.
• Any procedure not listed is covered at 30% discount off provider's then current fees.
• Eligible dependents include your spouse or civil union partner and unmarried dependent children under age 26.
• Orthodontic treatment: must remain covered under the discount plan for the entire duration of treatment or risk additional costs.
• This program cannot be used with any other insurance or benefit coverage.
• This is not dental insurance.