DENTAL & VISION ENROLLMENT FORM

First Name is required.
Last Name is required.
Address is required.
City is required.
State is required.
Zip is required.
Date of Birth is required.
SSN is required.
Phone is required.
Email is required.
Gender is required.

Applications received by the 20th of a month will become effective the 1st of the following month.


Please select one of the following dental products.
Dental Product is required.
Coverage with the past 60 days is required.

Please select one of the following vision plans.
 
Please select one of the following vision products.
Vision Product is required.

PISI Dental & Vision Program

Monthly Dental Rates
Individual: $33.62

Monthly Standard Vision Rates
Individual: $5.25
Two-Party: $9.25

Monthly Enhanced Vision Rates
Individual: $8.00
Two-Party: $14.00

 


Your spouse and dependent children up to the month they turn age 26 are eligible for coverage.
Disabled dependent children 26 and older may be covered indefinitely.

Number of Dependents is required.
Information for Dependent 1

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 2

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 3

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 4

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 5

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 6

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 7

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 8

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 9

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 

Information for Dependent 10

Coverage is required.

First Name is required.
Last Name is required.
Date of Birth is required.
SSN is required.
Gender is required.
Relationship is required.

 


Account Type is required.
Account Holder First Name is required.
Account Holder Last Name is required.
Routing Number is required.
Confirm Routing Number is required.
Account Number is required.
Confirm Account Number is required.
Benefits Enrollment Form Image

Authorization to honor drafts by the Professional Insurance Services, Inc. (PISI).

Authorization is required.

Any person who knowingly and with intent to defraud any insurance company or other person who files an application for insurance or statement of claim containing any materially false information or conceals for the purposes of misleading information concern­ing any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I hereby apply for the coverage indicated, and understand that the premium payment is for 12 months of coverage and is not refundable for any reason. If I do not renew my contract at the end of the 12 months, I cannot re-enroll for 36 months. I further understand that my enrollment is subject to receipt of payment in the correct amount. If a check is returned due to insufficient funds, a $20.00 fee will be charged.