Employers Dental Services: Individual Plan Enrollment

New Member Enrollment Form

Choose the plan that best fits you!

High Option	Cost for 1 year	Select One
Adult Only	$209.28
Adult + 1 dependent	$344.16
Adult + 2 dependents	$447.72
Adult + 3 or more dependents	$555.24
Child Only (to age 18)	$140.88
Low Option
Adult Only	$175.56
Adult + 1 dependent	$288.84
Adult + 2 dependents	$376.08
Adult + 3 or more dependents	$462.60
Child Only (to age 18)	$116.28

Member Information

Required

First Name

Last Name

Date of Birth

Mailing Address

City

State

Zip Code

Daytime Phone Number

Alternate Phone Number

Email Address

Confirm Email Address

If your billing information is different than your member information

Billing Information

Required

First Name

Last Name

Billing Address

City

State

Zip Code

Billing Phone Number

Provider Information

Benefits are available at your selected contracted dental facility only. Required
Look up your dental provider

Provider ID Number

Dental Office Name

Referral Information

Please let us know how you heard about us

If you were referred to Employer Dental Services by your insurance agent, broker or an Employer Dental Services representative, please provide their name.

Effective Date

Your plan will take effect on 05/01/2024.

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