High Plan – Individual and One or More Children

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$34.88 USD / Monthly (recurring charge)

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First Name *

Last Name *

Email Address *

Username (lowercase alphanumeric) *

Password (type this twice please) *

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Additional Info

Current Address

Street Address *

Apt/Suite

City *

State *

Zip Code *

Sex *

Personal Details

Date of Birth *

Last 4 Digits of Social Security Number *

Work Phone

Home Phone

Mobile Phone

Office Provider / Dentist Selection

List all dependents to be covered under this policy:

Name (1st Dependent)

Relationship (1st Dependent)

Date of Birth (1st Dependent)

Sex (1st Dependent)

Office Provider / Dentist Selection (1st Dependent)

Name (2nd Dependent)

Relationship (2nd Dependent)

Date of Birth (2nd Dependent)

Sex (2nd Dependent)

Office Provider / Dentist Selection (2nd Dependent)

Name (3rd Dependent)

Relationship (3rd Dependent)

Date of Birth (3rd Dependent)

Sex (3rd Dependent)

Office Provider / Dentist Selection (3rd Dependent)

Name (4th Dependent)

Relationship (4th Dependent)

Date of Birth (4th Dependent)

Sex (4th Dependent)

Office Provider / Dentist Selection (4th Dependent)

Name (5th Dependent)

Relationship (5th Dependent)

Date of Birth (5th Dependent)

Sex (5th Dependent)

Office Provider / Dentist Selection (5th Dependent)

Electronic Signature

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or any application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

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Card Start Date (mm/yyyy), or Issue Number *

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Postal / Zip Code *

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