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Texas 2009
Dental Plansfor Individuals, Families & Self Employed
When can I begin receiving dental care?Discount Plan• - can begin receiving benefits and dental care the day they enroll.Co-Pay & Co-Insurance Plans• - the policy and benefits become effective the 1st day of the month following the date we receive your enrollment.
How do waiting periods affect my dental care?Discount Plan• – There are no waiting periods.Co-Pay & Co-Insurance Plans• – No waiting periods for preventive care (cleanings, oral exams, etc). Waiting periods do apply to basic and major services; however, even before waiting periods are met, members pay lower contracted fees for all covered services from in-network dental providers.
What if my dental provider does not participate on a Dental Select network?Discount Plan• – No out-of-network discounts. Member must receive dental care from a Silver Network provider to receive discounts. Co-Pay Plans• – After deductibles and waiting periods are met, Co-Pay Plan members receiving dental care from a general dentist will receive an out-of-network benefit, which pays according to the Schedule of Co-Payments.Co-Insurance Plans• – After deductibles and waiting periods are met, all Co-Insurance Plans pay an out-of-network benefit, according to the plan fee schedule.
All charges over the plan payment will be the member’s responsibility.
Do I get benefits for orthodontia work?Discount, Co-Pay and Co-Insurance (Option 1) Plans• – From the plan’s effective date, all members receive a 20% discount on all covered orthodontic services when using an in-network dental provider.Co-Insurance (Option 2) Plans • – Members receive a 20% discount plus a 50% paid benefit (for children under 19) once the 24 month orthodontia waiting period is met, subject to plan maximums. Before the waiting period is met, all members receive a 20% discount on all covered orthodontic services when using an in-network dental provider.
What if I require services from a dental specialist?Most general dentists will perform specialist services. In the event one is needed, specialists include Endodontists, Periodon-tists, Pediatric Dentists, Orthodontists, Prosthodontists, and Oral Surgeons.
Discount Plan• – Members receive discounts on all services from in-network specialists.Co-Pay Plans• – Members receive a 20% discount on all services provided by an in-network specialist. No waiting periods or deductibles apply. Co-Insurance Plans• – After waiting periods and deductibles are met, members receive a paid benefit for covered services provided by both general dentists and specialists. In addition, you can save on out of pocket expenses when visiting an in-network provider.
What if I need services before my waiting periods or deductibles are met?Even before waiting periods and deductibles are met, members receive lower contracted fees for all covered •services from network providers.
Help Me Choose A Plan
Three easy ways to enroll:Enroll online at 1. www.dentalselect.com & waive the $15 enroll-ment fee, or call a Dental Select representative at 1-800-999-9789Fill out the attached enrollment form and return to Dental Select with 2. your $15 enrollment fee included Call your insurance agent3.
Why Dental Select?
Value of Dental InsuranceYou are twice as likely to receive regular dental check-ups with dental insurance. For every $1 you spend in preventive dental care you could save $8 to $50 in restorative and emergency treatment. Regular dental check-ups along with healthy teeth and gums not only saves you money, but will also:
Your Savings with Dental Select!
•Reduceyourriskofaheartattackupto150%•Reducetheriskofprematureandlowbirthweightbabiesby700%•Decreaseawoman’sriskofdevelopinggestationaldiabetes•Significantlyreducecomplicationsassociatedwithdiabetes•Decreasethemostcommonchronicchildhooddisease–toothdecay•Ensureearlydetectionandincreaseyourchanceofsurvivingoralcancer
Over 20 years of experience providing dental insurance to •individualsGuaranteed acceptance and renewal•Dental insurance experts•Community partner through the Sealants for Smiles program •whichappliessealantstoover4,700underprivilegedchildren each yearChoice of Discount, Co-Pay & Co-Insurance Plans with a wide •range of monthly premiums
Fast claims payment & accuracy•Cosmetic discount available for bleaching, veneers, etc.•Quality Contracted Providers • (as of Oct. 1, 2008)
ADA Code Description
Average Cost
Discount Plan
You Pay
Co-pay Gold Plan
(TX-3) You Pay
Co-pay Platinum
Plan (TX-3)
You Pay
Co-Insurance
Gold Option 1You Pay
Co-Insurance PlatinumOption 1You Pay
Co-Insurance
Gold Option 2You Pay
Co-Insurance PlatinumOption 2You Pay
D0120 Routine Checkup $37.18 $15.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
D1110 Adult Cleaning $73.51 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
D1120 Child Cleaning $50.74 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
D1203 Fluoride (age 14 & under) $25.81 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
D2140 Filling - 1 surface (silver) $116.83 $43.00 $0.00 $0.00 $13.80 $17.70 $9.20 $11.80
D2391 Filling - 1 surface (white) $138.95 $69.00 $34.00 $34.00 $23.70 $25.80 $15.80 $17.20
D2750 Crown - porcelain $932.92 $482.00 $310.00 $349.00 $255.00 $283.50 $255.00 $283.50
D3330 Molar Root Canal $963.35 $380.00 $272.00 $392.00 $197.00 $280.00 $197.00 $280.00
D4341 Periodontic Root Planing $190.64 $103.00 $86.00 $99.00 $53.00 $64.00 $53.00 $64.00
D7111 Extraction of Primary Tooth $90.15 $50.00 $31.00 $32.00 $18.90 $20.70 $12.60 $13.80
D7210 Surgical Extraction $206.97 $88.00 $60.00 $80.00 $30.30 $37.20 $20.20 $24.80
Dental Insurance = Healthier YOU
Silver over 1,800 providers•Gold over 2,300 providers•Platinum Co-Pay over 3,000 providers•Platinum Co-Insurance over 6,400 providers•Over 58,000 providers nationwide • (Platinum Co-Insurance only)
Average cost shown is based on the most heavily populated zip codes for contracted providers in Texas. Your payment is subject to waiting periods, deductibles & plan maximums. Savings based on services performed by a contracted provider.
Type
of P
lan
Fee-
for-
serv
ices
dis
coun
t pla
nco
ntra
cted
pro
vide
r dis
coun
t onl
y ◊
Insu
red
PPO
Insu
red
PPO
Cont
ract
ed o
r Non
-Con
tract
ed P
rovi
der
Cont
ract
ed P
rovi
der
Non-
Cont
ract
ed P
rovi
der
Optio
n 1
Optio
n 2
Prev
entiv
eCl
eani
ngs
(2 p
er ye
ar),
exam
s, fl
uorid
e (1
4 &
unde
r) an
d x-
rays
Up
to 9
0%Fe
e Re
duct
ion
100%
Refe
r to
Par
tial S
ched
ule
of
Co-P
aym
ents
No
n-Co
ntra
cted
D.S
. Pay
men
t
100%
100%
Basi
cIn
clud
es fi
lling
s an
d or
al s
urge
ryU
p to
60%
Fee
Redu
ctio
nU
p to
70%
Cov
erag
e70
%80
%
Maj
orIn
clud
es c
rown
s, b
ridge
s, p
erio
dont
ics,
end
odon
tics
& de
ntur
esU
p to
50%
Fee
Redu
ctio
nU
p to
50%
Cov
erag
e50
%50
%
Dedu
ctib
lePe
r cal
enda
r yea
r. M
axim
um th
ree
per f
amily
Appl
ies
to a
ll se
rvic
esN
one
$25/
$75
$75/
$225
$50/
$150
Max
imum
Ben
efit
Appl
ies
to a
ll se
rvic
es e
xclu
ding
orth
odon
tics
Per p
erso
n, p
er c
alen
dar y
ear
No
Max
imum
No
Max
imum
$1,0
00(o
f whi
ch $
500
per y
ear c
an b
e us
ed fo
r Maj
or S
ervi
ces)
Wai
ting
Peri
ods:
Basi
c
Maj
or
Orth
odon
tic
Non
e
Non
e
Non
e
6 M
onth
s
12 M
onth
s
Non
e
6 M
onth
s
18 M
onth
s
Non
e
6 M
onth
s
15 M
onth
sDi
scou
nt -
None
Insu
red
- 24
mon
ths
Net
wor
k Op
tions
Silv
erGo
ldPl
atin
umGo
ldPl
atin
umGo
ldPl
atin
um
Mon
thly
Rat
esSi
ngle
$8$1
5$2
0$1
7$2
2$2
3$3
0
Two
Party
$11
$29
$37
$32
$40
$43
$55
Fam
ily$1
5$4
2$5
5$4
3$5
5$5
7$7
4◊ Th
e Di
scou
nt P
lan
is n
ot a
den
tal i
nsur
ance
po
licy.
This
pro
gram
pro
vide
s di
scou
nts
only
from
a c
erta
in n
etwo
rk o
f den
tal p
rovi
ders
. The
m
embe
r is
resp
onsi
ble
to p
ay fo
r all
serv
ices
but
wi
ll re
ceiv
e a
disc
ount
from
den
tal p
rovi
ders
who
ar
e co
ntra
cted
on
Dent
al S
elec
t’s S
ilver
Net
work
.
S
ee P
artia
l Ben
efits
Sch
edul
e &
Sche
dule
of M
embe
r Fee
s fo
r det
ails
The
bene
fits
illus
trat
ed a
re in
sum
mar
y fo
rm o
nly.
The
y sh
ould
not
be
cons
true
d as
com
plet
e in
and
of
them
selv
es. Th
ey a
re f
or c
ompa
riso
n an
d in
cas
e of
dis
crep
ancy
, th
e pl
an d
ocum
ents
app
ly.
Ple
ase
refe
r to
the
pla
n ce
rtifi
cate
boo
klet
for
a c
ompl
ete
desc
ript
ion
of
bene
fits,
lim
itat
ions
& e
xclu
sion
s.
Plan
Sum
mar
y of
Ben
efits
Disc
ount
Pla
nCo
-Pay
Pla
nsCo
-Ins
uran
ce P
lans
Can
I vis
it a
non-
cont
ract
ed
dent
al p
rovi
der?
No
Yes
- Ge
nera
l Den
tist O
nly
(Rec
eive
a 2
0% d
isco
unt f
or c
ontra
cted
spe
cial
ists
, no
othe
r ben
efits
app
ly)Ye
s
Whe
n is
my
plan
effe
ctiv
e?Av
aila
ble
the
day y
ou e
nrol
l1s
t day
of t
he fo
llowi
ng m
onth
from
the
date
we
rece
ive
your
enr
ollm
ent
Who
can
I in
clud
e on
my
plan
? Sp
ouse
, Chi
ldre
n, G
rand
child
ren,
Par
ents
&
Gran
dpar
ents
Spou
se &
any
unm
arrie
d ch
ildre
n up
to a
ge 2
5
AC
E U
SA is
the
U.S
. do
mes
tic o
pera
ting
divi
sion
of
AC
E Li
mite
d. I
nsur
ance
pro
duct
s an
d se
rvic
es a
re p
rovi
ded
by t
he U
.S.
insu
ranc
e un
derw
ritin
g co
mpa
nies
and
not
by
AC
E Li
mite
d. T
his
plan
of
insu
ranc
e is
und
erw
ritt
en b
y A
CE
Am
eric
an I
nsur
ance
Com
pany
.
Orth
odon
tics
Child
ren
& A
dults
20%
Dis
coun
t(C
ontra
cted
Pro
vide
r)20
% D
isco
unt
(Con
tract
ed P
rovi
der)
No
Cove
rage
20%
Dis
coun
t(C
ontra
cted
Pro
vide
r)
Adul
ts –
20%
Dis
coun
t (Co
ntra
cted
)
Child
ren
unde
r19
– 50
% In
sure
d af
ter
20%
Dis
coun
t (Co
ntra
cted
)
Orth
odon
tic M
axim
umN
o M
axim
umN
o M
axim
umN
o M
axim
um$5
00 p
er y
ear
$1,0
00 li
fetim
e m
axim
um
Disc
ount
Vis
ion
incl
uded
for y
our e
ntire
fam
ily o
n ev
ery
plan
Part
ial S
ched
ule
of C
o-Pa
ymen
tsD
educ
tible
s: C
o-P
ay P
lans
onl
y (a
pplie
s to
all
serv
ices
) -
$25
per
pers
on /
$75
fam
ily m
axim
umG
ener
al A
reas
GO
LD &
PLA
TIN
UM
ON
LY
TX-1
: San
Ant
onio
TX
-2: A
ustin
/Wac
o T
X-3:
Dal
las
/ FT.
Wor
th, H
oust
on, C
orpu
s C
hris
ti, E
l Pas
o C
o-pa
ymen
t sch
edul
es a
re b
ased
on
your
net
wor
k pr
ovid
er’s
zip
cod
e. Y
ou w
ill r
ecei
ve a
com
plet
e lis
t of c
o-pa
ymen
ts w
ith y
our
ID c
ard.
Code
P
roce
dure
Des
crip
tion
Plat
inum
Gold
Silv
er*
TX-1
TX-2
TX-3
TX-1
TX-2
TX-3
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
t
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
t
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
t
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
t
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
t
Gene
ral D
entis
tCo
ntra
cted
Pro
vide
r Pa
tient
Co-
Pay
Non-
Cont
ract
ed
D.S.
Pay
men
tCo
ntra
cted
Pro
vide
r Pa
tient
Fee
PREV
ENTI
VE
D120
Ro
utin
e ch
ecku
pD1
50
Com
preh
ensi
ve e
xam
D210
X-
rays
, com
plet
e se
tD2
74
X-ra
ys,4
bite
wing
sD3
30
X-ra
ys, p
anor
amic
D111
0 Ad
ult c
lean
ing
D112
0 Ch
ild c
lean
ing
D120
3 Fl
uorid
e (a
ge 1
4 &
unde
r)
BASI
C D1
351
Seal
ant -
per
toot
h (a
ge 1
4 &
unde
r)
F
illin
gs
D215
0 Am
alga
m (s
ilver
) - 2
sur
face
D233
1 Co
mpo
site
(whi
te) -
2 s
urfa
ce a
nter
ior
D239
2 Co
mpo
site
(whi
te) -
2 s
urfa
ce p
oste
rior
Ext
ract
ions
D7
111
Extra
ctio
n-P
rimar
ytoo
thD7
140
Extra
ctio
n-P
erm
anen
ttoo
th
CROW
NS
D275
0Cr
own
-por
cela
inD2
950
Core
bui
ld u
p
ENDO
DONT
ICS
(ROO
T CA
NALS
) D3
320
Bicu
spid
root
can
alD3
330
Mol
ar ro
ot c
anal
PERI
ODON
TICS
D4
341
Perio
dont
ic ro
ot p
lani
ngD4
910
Perio
dont
ic m
aint
enan
ce
PROS
THOD
ONTI
CS (D
ENTU
RES)
D5
110
Com
plet
e de
ntur
e - u
pper
D512
0 Co
mpl
ete
dent
ure
- low
er
ORAL
SUR
GERY
D7
210
Surg
ical
ext
ract
ion
D723
0Su
rgic
ale
xtra
ctio
n-i
mpa
cted
MIS
CELL
ANEO
US
D099
9 OS
HA in
fect
ion
and
ster
iliza
tion
0 0 0 0 0 0 0 0 12 0 30 43 26 33 340
92 273
380
88 54 691
691
75 121 0
25 30 59 29 50 51 36 13 16 68 55 68 32 37 212 0 137
164
26 20 187
187
41 60 0
0 0 0 0 0 0 0 0 12 0 31 43 29 35 346
96 280
381
93 59 702
702
78 130 0
26 32 60 30 52 51 38 13 17 70 56 68 35 39 216 0 140
164
28 22 189
189
43 63 0
0 0 0 0 0 0 0 0 13 0 32 43 32 36 349
101
288
392
99 61 710
710
80 137 0
27 34 61 31 54 53 38 13 18 72 57 70 37 40 218 0 145
168
29 22 192
192
44 66 0
0 0 0 0 0 0 0 0 10 0 28 37 25 30 302
85 214
267
84 52 412
412
60 89 11
18 16 41 17 40 43 30 7 13 52 46 56 26 27 186 0 104
116
19 17 118
118
31 42 0
0 0 0 0 0 0 0 0 10 0 29 42 26 31 302
86 217
269
85 53 417
417
60 92 11
20 17 42 18 42 44 31 7 14 55 46 57 28 29 195 0 106
119
20 17 120
120
34 44 0
0 0 0 0 0 0 0 0 11 0 31 42 31 35 310
89 219
272
86 54 422
422
60 94 11
21 18 44 18 43 45 33 9 15 56 47 59 32 33 200 0 107
122
20 18 125
125
41 47 0
15 16 40 16 40 42 30 7 22 52 72 90 50 57 482
65 315
380
103
69 530
530
88 131
11
* D
isco
unt o
nly
Th
is is
not
a c
ompl
ete
list o
f pro
cedu
res.
You
will
rece
ive
the
com
plet
e ve
rsio
n wi
th yo
ur p
lan
ID c
ard.
Any
pro
cedu
re n
ot li
sted
in th
e co
mpl
ete
vers
ion
is a
vaila
ble
on a
fee-
for-
serv
ice
basi
s, n
o di
scou
nt w
ill a
pply.
Thi
s sa
mpl
e of
fees
is v
alid
thro
ugh
Dece
mbe
r 31,
200
9.
Access Discount Vision
If you would like a simple and carefree vision plan with savings of up to 40% at more than 40,000 independent providers and retail stores such as LensCrafters, Pearle Vision, Sears Optical, and Target Optical, this is the vision plan for you. Your entire family can be included, as long as they are also on your dental plan.
- No maximums - No waiting periods- No limits on number of visits- No claims to submit- No limits on amount of purchase
- All styles, sizes and materials are included- Includes contact lenses- Receive a discount of 5 - 15% on laser vision
correction surgery- Large nationwide panel of providers
access Vision FeaTures
The ACCESS Vision Plan is a fee for service discount plan, it is not an insured product. This program provides discounts only from a certain network of vision providers. The member is responsible to pay for all services but
will receive a discount from vision providers who are contracted on the Access Network.
summary oF Vision BeneFiTs
Vision Care Services Member Cost
Exam with Dilation as Necessary:* $5 off routine exam$10 off contact lens exam
Complete Pair of Glasses Purchase: frame, lenses and lens options must be purchased in the same transaction to receive full discount.
Standard Plastic Lenses: Single Vision Bifocal Trifocal Progressive
$50$70
$105$135
Frames: Any frame available at provider location 35% off retail price
Lens Options: UV Coating Tint (Solid & Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Anti-Reflective Coating Other Add-ons & Services
$15$15$15$40$45
20% Discount
Contact Lens Materials: (Discount applies to materials only) Disposable Conventional
N/A15% off retail price
Laser Vision Correction: Lasik or PRK
15% off retail price -or- 5% off promotional price
* Under contract, ACCESS Vision Providers may charge usual & customary rates for a comprehensive exam up to a contracted fee per region.
Discount Vision included for your entire family on every plan
Annual & Monthly Billing Options
MONTHLY payments are taken via automatic withdrawal or charge from:Checking or Savings account; or1. Credit or Debit Card. (Visa or Master Card)2.
Note: Premiums are drafted on the 16th of the month or the next 2 business days. On Co-Pay and Co-Insurance plans, premiums are paid one month in advance. For Discount plans, premiums are paid for the current month. When enrollments on Co-Pay or Co-Insurance plans are received after the 14th of the month, they will be charged for two months of premium (one for the month that the enrollment became effective and one for the month following) on the 16th of the month or the next business day; thereafter, they will be drafted for just one month.
ANNUAL Payments can be made by:Annual Check1. Credit Card Payment (Visa or Master Card)2.
Note: if annual payment is made by credit card, upon yearly renewal we will automatically charge the credit card 2 weeks in advance of the annual renewal date, unless a check is received before this time. At renewal, you can change to a monthly payment option.
How do I cancel?All cancelation requests must be received in writing. Your cancelation will be effective the first day of the month following the month your written request is received.
DenTal Plan exclusions
1. for services and supplies not listed in the Coverage Schedule, not recognized as essential for the treatment of the condition according to accepted standards of practice or considered experimental.
2. for services provided by Specialists whether Contracted or Non-Contracted. (Co-pay plans only)
3. for cosmetic procedures, including but not limited to veneers and bleaching of teeth and procedures performed primarily for cosmetic reasons.
4. for services related to, performed in conjunction with, or resulting from a non-covered procedure.
5. for charges in excess of the contracted Fee-for-Service schedule or the Reasonable and Customary rate, whichever applies.
6. for any treatment program which began prior to the date the Insured is covered under the Policy.
7. for crowns, inlays and onlays on teeth that can be restored by direct placement materials.
8. for the replacement of crowns, bridges, inlays, onlays or prosthetic appliance within 5 years from the date of last placement.
9. for service or supplies payable under any medical expense, auto or no-fault plan.
10. for any condition covered under any Worker’s Compensation Act or similar law.
11. for services applied without cost by any municipality, county or other political subdivision or for which there would be no charge in the absence of insurance.
12. for services that are applied toward the satisfaction of a Deductible, if any.
13. for services subject to a waiting period that were incurred during the waiting period.
14. for charges resulting from changing from one provider to another while receiving treatment, or from receiving treatment from more than one provider for one dental procedure to the extent that the total charges billed exceed the amount incurred if one provider had performed all services.
15. for hospital facility charges for any dental procedure, including but not limited to: emergency room charges, surgical facility charges, hospital confinement.
16. for drugs or the dispensing of drugs.17. for oral hygiene instruction; plaque control; acid etch;
prescription or take-home fluoride; broken appointments; completion of a claim form; OSHA/Sterilization fees (Occupational Safety & Health Agency); or diagnostic photographs (except for orthodontic purposes).
18. for implants; myofunctional therapy; athletic mouthguards; precision or semi-precision attachments; treatment of fractures, cysts, tumors, or lesions; maxillofacial prosthesis; orthognathic surgery; TMJ dysfunction; cleft palate; or anodontia.
19. for orthodontia, unless included within the Coverage Schedule.
20. for the replacement of a filling within 24 months of placement, unless for specific health reasons.
21. for composite, resin, or white fillings on posterior primary teeth. Benefit will be reduced to that of an amalgam or silver filling.
22. for the replacement of retainers. 23. for sealants not applied to permanent bicuspid or molar;
applied at age 15 or older; applied 3 years from a previous sealant application; applied to a decayed tooth.
24. for lab fees for higher metals or porcelain crowns, bridges, inlays or onlays.
25. for general anesthesia or IV sedation. (Co-pay plans only)26. for services to replace teeth that were missing (extracted or
congenitally) prior to the effective date of coverage on Our Plan. This limitation ends after 36 months of continuous coverage on the Plan. Abutment teeth will be reviewed for eligibility of prosthetic benefits. This exclusion does not apply if the device covers one or more natural teeth lost or extracted while covered under the Plan, or if the prosthetic device was in place when the policy became effective.
27. during travel or activity outside the United States.
No benefits will be paid:
TX2009 INDIVIDUAL 10/08
This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims.
The benefits illustrated are in summary form only. They should not be construed as complete in and of themselves. They are only for comparison and in the case of discrepancy the plan documents apply. Please refer to the certificate for a complete description of benefits, limitations, and exclusions.
Soc
ial S
ecur
ity N
o.
Firs
tLa
st N
ame
Initi
al
Hom
e A
ddre
ssC
ity
Sta
teZi
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ode
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ital S
tatu
sR
eque
sted
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ctiv
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ate
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e of
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hS
exM
ale
Fem
ale
Yes
N
o
Sex
Sex
Hom
e Te
leph
one
Whe
re d
id y
ou h
ear a
bout
us?
LIS
T A
LL D
EP
EN
DE
NTS
TO
BE
CO
VE
RE
D
Spo
use
1. C
hild
2. C
hild
3. C
hild
4. C
hild
5. C
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7. C
hild
Firs
t Nam
e
Dat
e of
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Mar
ried
S
ingl
e
M M M MF F F F
Please fill out and return this enrollment formwith your payment to:
PLEA
SE F
ILL
OU
T TH
E R
EVER
SE S
IDE
OF
THIS
EN
RO
LLM
ENT
FOR
MTe
xas
- In
divi
dual
Den
tal P
lan
Enro
llmen
t Fo
rm
Age
nt ID
Num
ber
DENTAL SELECT - CORPORATE OFFICE5373 S. GREEN STREET, 4th FLOORSALT LAKE CITY, UTAH 84123Toll Free (800) 999-9789Toll Free Fax (888) 998-8711
Age
nt N
ame
Do
you
or a
ny fa
mily
mem
ber h
ave
othe
r den
tal i
nsur
ance
?If
Yes,
nam
e ot
her d
enta
l ins
uran
ce c
ompa
ny Firs
t Nam
e
D
.O.B
.
Em
ploy
er’s
Nam
e &
Pho
ne N
umbe
r
1,20
0S
T
Enro
ll on
line
at w
ww
.den
tals
elec
t.com
Per
son
Ass
igne
d A
s P
olic
y H
olde
rS
ocia
l Sec
urity
No.
M M M MF F F F
Please Complete Both Sides
Choose your Plan (Choose only one)
Payment Options (Choose either Checking/Savings or Credit Card Paym
ent)
Discount PlanBilling Period: M
onthly (Withdrawn on the 16th or next 2 business days) Annual (Check or Credit Card)
Silver Netw
orkChecking or Savings (Include a $15.00 enrollm
ent fee with your payment)
Co-Pay PlansC
hecking Account (Include Voided C
heck) Savings Account (Include D
eposit Slip)
Gold N
etwork
Platinum
Netw
orkFinancial Institution:
Co-Insurance PlansR
outing Num
ber:
Option 1
Option 2
Account N
umber:
Gold N
etwork
Gold N
etwork
Credit Card Payment (Include your check for the $15.00 enrollm
ent fee)
Platinum
Netw
orkP
latinum N
etwork
VISA
MA
STE
RC
AR
D
Vision plan included with all dental P
lansA
ccount Num
ber: Exp. Date:
I wish to enroll in the plan I have selected. I authorize and agree to account deduction of
the required premium
.
Signature: Date:
Account H
older Nam
e:
Account H
older Signature: Date:
This authorization will rem
ain in effect until the financial institution has received and has had reasonable time to act on a w
ritten request from m
e to terminate this agreem
ent. I understand that I can stop a withdraw
al by notifying the financial institution at least three business days before the w
ithdrawal is m
ade. In the event of a withdraw
al error, I must prom
ptly notify the financial institution to preserve any rights I may have. P
lease direct billing inquiries to Dental Select, 5373 S. G
reen Street., 4th Floor, Salt Lake City,
UT 84123. I have read and understand the statem
ents above pertaining to the billing option. Your cancellation will be effective the first day of the m
onth following the m
onth your written request is received.
In the event there are insufficient funds when a draft is charged to m
y account, I agree to pay $25 NSF Fee. The 3rd returned check in any 12 m
onth period will result in the im
mediate cancellation of m
y policy. Dental Select reserves the right to deny m
e the ability to be reinstated on any Individual D
ental Select plan for two years.
AC
E USA
is the U.S. dom
estic operating division of AC
E Limited. Insurance products and services are provided by the U
.S. insurance underwriting com
panies and not by AC
E Limited. G
old and Platinum
plans of insurance are underwritten by A
CE A
merican
Insurance Com
pany.