YOUR MOMENTUM DENTAL INSURANCE PLAN OPTIONS

The Best Wisconsin Dental Insurance Coverage and Rates

Momentum Insurance provides Wisconsin residents with comprehensive coverage accepted state-wide, at unbeatable rates and affordable premiums. Seniors, college students, children, businesses, and single parents alike can select a dentist who accepts Momentum in our vast network approved of dentistry’s. We work with you to define the dental coverage you need at the cost that best fits your situation. Enroll today in under 4 minutes to receive awesome, affordable dental insurance.

Compare the costs and protections of Momentum's three plans below, or contact us with questions.

Dental insurance will vastly improve the overall health of you, your family, and your employees. Access to good dental care will help prevent harmful health risks, like heart disease. Our dental plans have high coverage and affordable premiums. We also have a vast network of dentists in Wisconsin to choose from.

Wisconsin Dental Plans for Individuals & Families

Momentum Insurance Plans, Inc. offers individual dental plans for Wisconsin residents of all backgrounds. Students, families, seniors, and other individuals need reliable dental insurance they can afford. Our plans are specifically designed to benefit our members by providing quality coverage of dental services with low premiums, insuring healthy smiles across Wisconsin.

Related: Top Five Reasons Young Adults Need Dental Insurance

Protect Individual Plan for Madison Area Residents

Momentum offers the Protect Individual Plan - a dental plan with just enough insurance for the minimal preventive dental care you need at a low monthly cost. With no deductible on your biannual teeth cleanings and dental exams. The Protect Individual Plan from Momentum is only applicable for care through our DHA network of providers. Dental Health Associates of Madison is one of the largest group dental practices in the Dane County area. Get affordable coverage through Momentum today and become a patient at one of Dental Health Associates of Madison’s seven locations for high quality dental care near your home or work.

Momentum Platinum & Gold Plans

Our Platinum and Gold Dental Plans each have low deductibles - just $50 per person and $150 per family - and both cover a wide range of dental services necessary for optimum dental health. If you choose our Platinum Plan, the deductible is waived for diagnostic and preventive services like exams, cleanings, X-rays, and sealants.

Our Gold Plan has its advantages in coverage too, at a lower price than the Platinum Plan. Premium costs are based on plan network (commercial, or Dental Health Associates) and the number of insured individuals.

Related: Is Dental Insurance Worth It?

Group Dental Insurance Plans for Wisconsin Businesses

Wisconsin businesses thinking about offering their employees dental benefits or shopping for a more affordable, flexible group plan, should get a quote from Momentum Plans.

Not only does offering excellent dental insurance to your employees create a healthier, happier workplace, it’s also a benefit which attracts talented applicants and retains your current, hardworking employees. Providing dental coverage to your employees shows you care about their health and well-being, which improves workplace morale and productivity. In many cases, employees are willing to pay the full premiums and appreciate the convenience of paying their costs through pre-taxed dollars.

Related: Small Business Dental Insurance Plans From Momentum

About Momentum Plans | Dental Insurance You Can Smile About

Founded in 2011, Momentum Plans originates in Madison, Wisconsin where we started offering high-quality dental insurance with the purpose of ensuring our friends and neighbors in Dane County would have access to affordable dental coverage.

Since then, Momentum has expanded its reach and is currently bringing great dental insurance and coverage to all parts of Wisconsin. We have been able to provide affordable oral health care plans to families, businesses, and individuals around the state, and we hope you’ll be next to take advantage of Momentum’s great offerings.

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Please contact us with any questions you have regarding your options with Momentum Plans.

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Plan and Coverage Options

Step 1 of 5

SELECT YOUR PLAN (must choose an option) compare plans

Protect Plan:

Dental Health Associates Network

Gold Plan:

Dental Health Associates Network Commercial Network

Platinum Plan:

Dental Health Associates Network Commercial Network

Coverage Type

Single Couple Limited Family (1 adult + 1 child) Family Child/Children Only Number of children One Two Three Four

Select the number of Dependents One Two Three Four Five

Requested Effective Date

(must be the 1st of an upcoming month): //

Price Per Month:

(Plan and Coverage Type are Required for Pricing)

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Member Information

Step 2 of 5

First Name*

MI

Last Name*

* Male Female

Home Address*

City*

State*

Zip Code*

Primary Phone*

- -

Email*

Marital Status Married Single

*Date of Birth

/ /

How have you heard about us?

Please Select an Option Referral by Momentum Insurance Agent Referral by Existing Momentum Customer Web Search I am a Repeat Customer Outdoor Billboards Radio Print Ad (Magazine/Newspaper) Television Social Media (Facebook/Twitter/LinkedIn) Other

Agents name:

Other:

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Dependent Information

Step 3 of 5

No dependent info is needed if you choose single in plan coverage.

1. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

2. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

3. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

4. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

5. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

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Coordination of Benefits & Prior Coverage

Step 4 of 5

Just a Couple More Questions:

Are you, your spouse, or other dependents(s) covered by any other dental plan that will remain in effect

Yes No

Which Family members will be covered? Self Spouse Dependent(s)

Select the number of Dependents

One Two Three Four Five

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Has applicant had previous dental coverage?

Yes No

Which Family members had previous insurance? Self Spouse Dependent(s)

Select the number of Dependents One Two Three Four Five

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /

Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

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Complete Your Purchase of a Momentum Insurance Plan

Step 5 of 5

MONTHLY COST:

Select Initial Payment Time:

3 Months

6 Months

12 Months

Total Due Today:

Cardholder Name:*

Email:*

Billing Address:*

City:*

State:*

Zip Code:*

Phone Number:*

Card Number:*

Expiration Date (MM/YY):*

Acceptance

I accept the Individual Plan coverage provided by Momentum Insurance Plans, Inc. I understand that by accepting insurance coverage, I am required to remit premiums according to the method of payment selected below on or before the 20th day of the month preceding the month of coverage for which payment is being made. Addition or deletion of dependents, and any other changes to coverage are allowed only based on a qualifying event as described in the Individual Plan policy. Coverage will be effective only upon acceptance and approval by Momentum Insurance Plans, Inc.

By signing this form, I certify that all information supplied is true to the best of my knowledge. I understand that all benefits for myself and my eligible dependents will be provided in accordance with the terms of the plan(s) in which I have enrolled and I agree to abide by the terms and conditions provided in the plan(s).

Please Sign The Electronic Signature Form Below

SAVE

CLEAR

Use your mouse or finger (if on touch screen device) to sign the document on the line above.

By my signature above, I authorize Momentum Insurance Plans, Inc. to initiate a debit entry to the credit card account (Discover, MasterCard, Visa) indicated above in the amount of 3 months premium for the initial payment. Each month thereafter, debits will be made on the 20th day of the month, prior to the coverage month, for each monthly payment. This authority is to remain in full force and effective until Momentum Insurance Plans, Inc. and said financial institution have received written notification from me of its termination in such time and manner as to afford Momentum Insurance Plans, Inc. and said financial institution reasonable opportunity to act upon it. This card will be used for reoccurring payments unless we hear from you. Please contact us at 608.729.6500 to make other arrangements for reoccurring payments.

Are you working with an agent?

Yes No

Agency Name

Agent Name

Agent #

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