Dental & Vision Insurance Plan

Dental & Vision Insurance Plan

Applicant / Insured Information

Applicant Name:

Date of Birth:    Phone:

Email:    SSN / Tax ID:

Policy Details

Plan Type: Dental Only Vision Only Combined Dental & Vision

Maximum Annual Dental Benefit:    Maximum Annual Vision Benefit:

Deductible (Dental):    Deductible (Vision):

Premium Amount (per billing period):

Policy Period: From to

Coverage Options

Select dental coverages included in this plan (benefit limits and frequency may apply):

Preventive services (cleanings, exams, x-rays)
Basic restorative services (fillings, extractions)
Major restorative services (crowns, bridges)
Orthodontia (limited lifetime benefit may apply)

Select vision coverages included in this plan:

Routine eye exam
Frames allowance
Lenses (single, bifocal, progressive)
Contact lens allowance
Advanced imaging or retinal services

Exclusions and Limitations

The following exclusions commonly apply unless specifically endorsed. Applicant must initial to acknowledge awareness where indicated.

Cosmetic services and procedures not necessary to restore function
Pre-existing conditions subject to waiting periods
Experimental or investigational treatments
Work-related or auto-accident injuries covered by other liability

Beneficiary / Payee Information

Primary Beneficiary Name:

Relationship:    Allocation Percentage:

Claim / Loss Reporting (for dental or vision claims)

Documentation provided with this claim (check all that apply):

Itemized invoice from provider
Radiographs / imaging
Treatment plan or estimate
Relevant medical/dental records

Declarations and Authorizations

I, the undersigned Applicant, certify that the information provided in this application is true, complete and correct to the best of my knowledge. I understand that material misrepresentation or omission may be the basis for denial of benefits or rescission of coverage. I authorize any dentist, physician, hospital, clinic, employer or other institution or person that has records or knowledge of me or my health to release information to the insurer for the purpose of underwriting, claim adjudication, fraud prevention, and treatment management.

I acknowledge that benefits are payable only as described in the plan provisions and are subject to deductibles, copayments, maximums, waiting periods and exclusions. Premiums are due in accordance with the policy schedule; failure to pay premiums when due may result in termination of coverage. Any assignment of benefits to a provider does not relieve the Applicant of responsibility for payment of premiums or for obtaining required referrals or prior authorizations.

Fraud Warning: Any person who knowingly and with intent to defraud submits an application or claim containing false or misleading information may be subject to civil or criminal penalties under applicable law.

Applicant Authorization: I authorize release of information as described above

Acknowledgment

By signing below, I acknowledge receipt of the plan summary and agree to the terms and conditions set forth in this Dental & Vision Insurance Plan. I understand that specific covered procedures, limitations, and benefit amounts are determined by the plan contract and that this application is not a guarantee of coverage until accepted by the insurer and premiums are paid in accordance with the policy.

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