Smile because you are covered by the nation’s oldest, largest and leading dental benefits company.
Here is a list of links to some important forms for subscribers. After selecting each link, use your web browser or PDF File/Print option in order to print each form.
Payment Form (For Exchange Certified Plans only) - For subscribers on an Individual Exchange Certified plan needing to update the credit card or ACH information on account.
Electronic Funds Transfer Form (For Individual Plans 85100/85200 only) - For subscribers on an Individual 85100/85200 plan needing to update the banking information used for monthly premium withdrawals.
Claim Form - To submit a dental claim to our office for processing.
Coverage Change Form Please contact your employer to submit this form - For subscribers needing to change a name, change their coverage, or add/remove a dependent.
* Adobe Acrobat 7.0 or higher is required to view the PDF forms. Click here to download the latest version of Adobe Acrobat.