Individual Dental Plan Application
S500
LAST NAME:
FIRST NAME:
MI:
ADDRESS:
CITY/STATE/ZIP:
HOME PHONE:
WORK PHONE:
SOC. SEC. #:
SPONSORING EMPLOYER:
CITY/STATE/ZIP:
SPOUSES NAME (if covered)*:
Date of Birth:
CHILDRENS NAME (if covered)*:
Date of Birth:
NAME:
Date of Birth:
NAME:
Date of Birth:
NAME:
Date of Birth:
NAME:
Date of Birth:
NAME:
Date of Birth:
Please check the desired coverage level:
Individual Only
$ 7.95
Individual + One
$ 11.95
Individual + Family
$ 15.95
ENROLLMENT FEE
$ 15.00
Below are (3) three Methods of Payment
Choose (1) one
Method of Payment
and (1) one
Mode of Payment
.
I want to pay by Bank Draft:
Monthly Bank Draft
. I herby authorize you to pay checks drawn on my account by CAREINGTON International, and payable to same provided there are sufficient collected funds in said account to pay the same upon presentation.
BANK DRAFT enclose a check for first-month's premium payable to Network Dental Plan.
I want to pay by CHECK,
payable to CAREINGTON International on a
Quarterly Basis
- enclose premium payments for
3 months
with application.
Semi-Annual Basis
- enclose premium payments for
6 months
with application.
Pay 6 months at time of application and receive Vision & Prescription Plans FREE!!!
Annual Basis
- enclose premium payments for
12 months
with application.
Pay 12 months at time of application and receive Vision & Prescription Plans FREE!!!
I want to pay by CREDIT CARD,
payable to CAREINGTON International on a
Quarterly Basis
Semi-Annual Basis
Annual Basis
Visa
MasterCard
American Express
Discover
ACCOUNT NUMBER:
EXPIRATION DATE:
NAME ON CARD:
SIGNATURE:
DATE: