Insurance Enrollment

Enrollment

Step 1 of 6

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I understand that this plan ONLY covers services at Dental Health Associates in Madison, WI*
- YES
This field is hidden when viewing the form
I understand that this plan ONLY covers services at Dental Health Associates in Madison, WI**
- YES
This field is hidden when viewing the form
I understand that this plan ONLY covers services at Dental Health Associates in Madison, WI**
- YES
First Name*
First
MI
Last Name*
Last
Gender*
Address*

Street Address Address Line 2 City State ZIP Code

Individuals must reside in Wisconsin to participate in a Momentum Insurance Plan.
Primary Phone*
Email*
Marital Status*
Date of Birth*
Month
Day
Year
How did you hear about Momentum?*
Agent's Name
Other:

No dependent info is needed if you choose Single in plan coverage on Page 1 of this form.
1. Dependent*
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Dependent's Relationship*
Please specify:*
2. Dependent*
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Dependent's Relationship*
Please specify:*
3. Dependent*
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Dependent's Relationship*
Please specify:*
4. Dependent*
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Dependent's Relationship*
Please specify:*
5. Dependent*
First Middle Last
Gender*
Date of Birth*
Month
Day
Year
Dependent's Relationship*
Please specify:*

Has applicant had previous dental coverage?*
- Yes
- No
Which family members had previous insurance?*
- Self
- Spouse
- Dependent(s)
Select number of dependents*
Self - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
Spouse - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
1 - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
2 - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
3 - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
4 - Name of person insured*
Policy #*
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year
5 - Name of person insured
Policy #
Name of previous plan/insurance company*
Coverage Started On*
Month
Day
Year
Coverage Ended On*
Month
Day
Year

Monthly Cost
Price: $0.00
Select Initial Payment Time:*
- 3 Months
- 6 Months
- 12 Months
Total Due Today:
Price: $0.00
Account Number
Name*
Billing Address*
Street Address City State ZIP Code
Email*
Phone*
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
Today's Date
MM slash DD slash YYYY
*
By my signature above, I authorize Momentum Insurance Plans, Inc. to initiate a debit entry to the credit card account (Discover, MasterCard, Visa) indicated on the next page 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 insurance agent?*
- Yes
- No
Agency Name
Agent Name
Agent #
Consent
I agree to the privacy policy.
Name
This field is for validation purposes and should be left unchanged.

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