No dependent info is needed if you choose single in plan coverage.
Are you, your spouse, or other dependents(s) covered by any other dental plan that will remain in effect
Has applicant had previous dental coverage?
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).
Are you working with an agent?
Please allow time for this process to complete.
Momentum Plans provide dental insurance to individuals and companies, drawing the majority of our clients from Madison, Milwaukee, Waukesha, Racine, Kenosha, Eau Claire, Green Bay, Appleton, Oshkosh, Janesville, Sheboygan, Fond du Lac, Wausau and the surrounding communities in Wisconsin.