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Enrollment Form Wellesley College 2009-395-1 IMPORTANT Coverage will not begin until payment is received and processed. Send completed application with check made payable to UnitedHealthcare StudentResources to UnitedHealthcare StudentResources PO Box 809026 Dallas Texas 75380-9026. The Certificate provides dental benefits only. Review your Certificate carefully. SIGNATURE DATE Company of New York Hauppauge New York New York only or United Healthcare Services Inc. UnitedHealthcare Dental...
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Step 1: Obtain a copy of the 2009-395-1 dental enrollment form-v2qxp.
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Step 2: Read the instructions on the form carefully.
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Step 3: Fill in your personal information such as your name, address, and contact details in the designated fields.
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Step 4: Provide your dental insurance information, if applicable.
05
Step 5: Indicate your preferred dentist or dental clinic, if applicable.
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Step 6: Answer all the questions honestly and accurately.
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Step 9: Submit the form to the appropriate dental healthcare provider or organization.

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Individuals who wish to enroll in a dental insurance plan.
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Dependents who are eligible for dental coverage through a family member's insurance plan.
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People who want to update their dental enrollment information.
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395-1 dental enrollment form-v2qxp is a form used for enrolling in a dental insurance plan.
Employees who wish to enroll in the dental insurance plan must file the 395-1 dental enrollment form-v2qxp.
To fill out the 395-1 dental enrollment form-v2qxp, individuals must provide their personal information, including name, contact details, and insurance preferences.
The purpose of 395-1 dental enrollment form-v2qxp is to gather information from individuals who wish to enroll in the dental insurance plan.
The 395-1 dental enrollment form-v2qxp requires individuals to report their personal information, insurance preferences, and any dependents they wish to include in the plan.
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