Enrollment

Step 1 of 5

SELECT YOUR PLAN (must choose an option)

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

Requested Effective Date

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

Price Per Month:

(Plan and Coverage Type are Required for Pricing)

Step 2 of 5

First Name*

MI

Last Name*

* Male Female

Home Address*

City*

State*

Zip Code*

Primary Phone*

- -

Email*

Marital Status

*Date of Birth

/ /

How have you heard about us?

Step 3 of 5

No dependent info is needed if you choose single in plan 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)

Has applicant had previous dental coverage?

Yes No

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

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 (MMYY):*

Discover, Visa, MasterCard, American Express

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

SELECT YOUR PLAN (must choose an option)

Coverage Type

Requested Effective Date

Acceptance

Standby - We are processing your request.