Connection Dental Plus Online Enrollment
Thank you for your interest in Connection Dental Plus. You can enroll online by completing the following information.
If you need assistance with enrollment, please call us at (800) 793-9335 Monday-Friday from 7 a.m. to 5:30 p.m. Central Time.
*Indicates required information
Current or Former Federal Employee or Survivor Annuitant
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
Gender
Male
*
Female
Social Security Number
*
(No dashes. Example: 123456789) This information is for enrollment purposes only. To protect your privacy,
Connection Dental Plus will issue you a unique Dental ID number for benefit purposes.
Are you a Survivor Annuitant?
Yes
*
No
If yes, please provide your Social Security Number
Phone Number
*
(xxx-xxx-xxxx for U.S. numbers)
Physical Address
Street Address
*
City
*
State/Province
Zip Code
*
Country
*
Is mailing address different from physical address?
Yes
No
If "Yes," complete the Mailing Address section below. If "No," then skip down to Employment Information.
Mailing Address
Street Address
City
State/Province
Zip Code
Country
Employment Information
Federal agency where applicant is employed or was employed
*
Federal employment status
Active
*
Retired
Former
If you are employed with the U.S. military, please indicate
Civilian
Non-Civilian
Coverage
Please select coverage option and enter information for your spouse or dependent children, as applicable. Connection Dental Plus
eligible dependents are your legally married spouse and each unmarried child who is under age 26. Eligible dependents can be enrolled only
if the federal employee or annuitant enrolls.
Select Coverage Option
*
Number of Dependent Children
*
Are you married?
Yes
*
No
Dependent Spouse Information
First Name
*
Middle Initial
Last Name
*
Date of Birth
Gender
Male *
Female
Social Security Number
*
(No dashes. Example: 123456789)
Dependent Child 1 Information
First Name
Middle Initial
Last Name
Date of Birth
Gender
Male
Female
Relationship
Natural Child
Other
If other, please explain
Social Security Number
(No dashes. Example: 123456789)
Dependent Child 2 Information
First Name
Middle Initial
Last Name
Date of Birth
Gender
Male
Female
Relationship
Natural Child
Other
If other, please explain
Social Security Number
(No dashes. Example: 123456789)
Dependent Child 3 Information
First Name
Middle Initial
Last Name
Date of Birth
Gender
Male
Female
Relationship
Natural Child
Other
If other, please explain
Social Security Number
(No dashes. Example: 123456789)
Dependent Child 4 Information
First Name
Middle Initial
Last Name
Date of Birth
Gender
Male
Female
Relationship
Natural Child
Other
If other, please explain
Social Security Number
(No dashes. Example: 123456789)
Additional Dependents
If you have additional dependents, please list their full names, dates of birth, genders, relationships and Social Security numbers in the space below:
FEHB or Additional Plan Information
Connection Dental Plus is a supplemental dental plan and will pay last after other coverage. Please provide the name of your current FEHB
and any other coverage information (if applicable). If you have waived FEHB coverage, please enter WAIVED in this field. If you are a former
Federal Employee no longer eligible for FEHB, please enter FORMER in this field.
The name of my Federal Employee Health Benefits (FEHB) plan is/will be:
*
The three-digit enrollment code for my FEHB plan above:
This information can be found on your FEHB plan ID card or the front of the plan brochure.
Do you, your spouse or any other eligible dependent(s) have medical/dental coverage, other than the FEHB plan listed above?
Yes
*
No
If no, proceed to Payment Options below. If yes, what is the name of the other insurance?
What is the effective date of policy of the other insurance?
What is the other insurance phone number?
(xxx-xxx-xxxx for U.S. numbers)
Who is the policy holder of the other insurance?
Please list the family members covered by the other insurance:
Payment Options
Please select how you will pay for your Connection Dental Plus coverage. After reading and accepting the terms and conditions below,
please press Submit to send us your application. Please allow us one to two weeks to process your application and mail your ID cards.
Your Connection Dental Plus coverage will not begin until the first of the month following receipt of your premium payment.
Monthly Premium: To view the current premiums, click Connection Dental Plus Premium Pricing
Select Payment Option
Monthly bank draft from Checking or Savings
*
Quarterly bank draft from Checking or Savings
Quarterly billing from Connection Dental Plus
Effective Date of Coverage
Your coverage will be effective the first of the month following receipt of your completed application and premium
payment. If you are requesting a later effective date of coverage, what month do you want coverage to begin?
Agree to Terms
I have read and understand the information below and hereby apply for Connection Dental Plus coverage for myself and my eligible dependent(s),
if any. The information provided by me on this application is true and correct to the best of my knowledge.
Accept
*
I decline, please cancel this application
The Connection Dental Plus plan is neither offered nor guaranteed under the contract with the FEHB program. You must notify Connection Dental
Plus of any enrollment changes. Your payroll office will not notify Connection Dental Plus for you. Benefits are subject to plan provisions,
limitations and exclusions. Please read the Connection Dental Plus Plan Brochure carefully as deductibles, waiting periods and maximum limits do apply.
If you have any questions or need assistance with this form, please call us at (800) 793-9335.