Forms

Helpful forms for managing benefits

Incorrect information could cause your employee’s Protected Health Information to be viewed by another party.

 

Enrollment Forms – Group Dental Plans

Please select and complete the appropriate form(s) below, then send your enrollment information by secure form submission, fax or mail.

• PPO Plans
  Choose the state where your group is headquartered:
  
  Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Spanish Enrollment Form (Not for use in CA, FL, HI, LA, MD, MI, MT, NJ, TN, VA, WA and WI.)

• DHMO Plans
  Choose the state where your employee resides:
  
  Select Your State Alabama California Washington D.C. Kentucky Maryland Michigan Missouri New Jersey Ohio Pennsylvania Texas

  Spanish Enrollment Form (Not for use in CA, MD, MI, NJ and TX.)

• USERRA Enrollment Form
  Use this for employees who serve temporarily in the uniformed services and wish to continue coverage for up to 24 months during deployment or to reinstate coverage after deployment.
  USERRA Enrollment Form

Ready to submit?

Access one of the 3 tabs below for sending enrollment by secure form, fax or mail. Depending on your request, your enrollment updates may take up to 10 business days to process.