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List spouse or civil union partner and unmarried dependent children under age 26 that you wish to enroll.

Dependent #1

Dependent #2

Dependent #3

Dependent #4

Annual Membership Fees
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Additional Information

 

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.

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