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Dominion Dental Services, Inc.
Arlington, VA Avalon Insurance Company
Harrisburg, PA
Dental Enrollment CardEnrollment Information
Last NameFirst Asocial Security Numbers. I.MF Birthdate (MM/DD/BY)Home
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How to fill out dental enrollment card
How to fill out dental enrollment card
01
Receive a dental enrollment card from your dental insurance provider or download it from their website.
02
Read the instructions carefully to understand what information needs to be filled out.
03
Provide your personal information such as name, address, date of birth, and contact details.
04
Provide your dental insurance information, including the policy number and the name of the insurance company.
05
Specify any dependents you want to include in the dental coverage.
06
Indicate any pre-existing dental conditions or specific treatments you may require.
07
Sign and date the enrollment card.
08
Submit the completed dental enrollment card to your dental insurance provider.
09
Keep a copy of the filled-out card for your records.
Who needs dental enrollment card?
01
Anyone who wants to enroll in a dental insurance plan.
02
Individuals who currently do not have dental coverage.
03
Employees who are required to enroll in their company's dental insurance plan.
04
Dependents of policyholders who want to be included in the dental coverage.
05
Individuals who want to switch to a different dental insurance provider.
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What is dental enrollment card?
Dental enrollment card is a form used to register for dental insurance coverage.
Who is required to file dental enrollment card?
Employees who wish to enroll in dental insurance coverage are required to file a dental enrollment card.
How to fill out dental enrollment card?
To fill out a dental enrollment card, you need to provide personal information, choose a dental insurance plan, and sign the form.
What is the purpose of dental enrollment card?
The purpose of dental enrollment card is to enroll individuals in dental insurance coverage.
What information must be reported on dental enrollment card?
The dental enrollment card typically requires information such as name, address, date of birth, social security number, and choice of dental insurance plan.
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