United Concordia Dental

Secure Enrollment Submission

If you are an employer, group representative, or administrator who would like to manage group enrollment, please complete the form below.

Conveniently Manage Enrollment

It’s easy to enroll your employees in 3 simple steps:

  1. Find the correct enrollment form for your state here, complete the form and save it.
  2. Enter the information into the required fields below.
  3. Attach the completed enrollment form and submit.

After your information and enrollment form have been received, we will notify you when the enrollment process has been completed.

Full Name is required.
Email is required.
Confirm Email is required.
Must use a 10 digit number.
Ext cannot exceed 5 characters.
Group Name is required.
Group Number is required.
A file must be attached. Please add and and save a file.
Please note the following:
  • Supported extensions: docx, rtf, pdf, jpeg, png, tiff, xlsx.
  • Maximum Number of Files: 5
  • Maximum file size: 15MB


Non-Discrimination Notice

United Concordia Dental complies with all applicable federal civil rights laws.