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.

Current or Former Federal Employee or Survivor Annuitant

Physical Address

Mailing Address

Street Address City State/Province Zip Code Country

Employment Information

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.

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

Dependent Child 3 Information

Dependent Child 4 Information

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.

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

Agree to Terms

If you have any questions or need assistance with this form, please call us at (800) 793-9335.