Phone: 800-296-0192 Fax: 650-591-4022 Web: www.dentalinfo.biz

To add new employees and/or dependents complete the following application and fax back to us

(Note: Coverage is not in effect until we receive and approve application. Charges for approved adds will appear on next invoice.)

Employee Information

Social Security # ____________-___________-_____________ Desired Effective Date ____________- 01- _____________

First Name _____________________________________ Last Name _______________________________________

Birth Date ____________-__________-______________ Gender Male____ Female____

Dependent Information

Last Name (if different) First Name Sex Relationship Birth Date

___________________________ ___________________________ M F __________ ________-_________-_________

Select Plan (must be the same as the rest of employees in the group): ___ Basic ___ Enhanced

Monthly Rates: Basic Plan Enhanced Plan

Employee Only 24.29 35.56

Employee + Family 56.99 78.38

To delete employees and/or dependents from your account

complete this top form and fax back to us

(Note: A maximum of 60 days will be credited for retro-active deletions submitted. Credits will appear on next invoice.)

Name of deleted employee or dependent Effective Date of Deletion

(if employee is deleted, all deps. of the employee will automatically be deleted) (must be last day of month)

________________________________________________________________ _______________________