Membership Application Instructions
1. COVERAGE: Complete the information for the person who is subscribing for membership.
2. OTHER FAMILY MEMBERS include: (1) Your spouse. (2) Your children until the age of 26 and your grandchildren who are in your legal custody and residing with you until the age of 26. (3)Your unmarried children who are handicapped.
4. CHOOSING A DENTIST: You must choose a dentist who is willing to service Q-Dentís prepaid policy. All Family Members must use the same dentist you choose. Before you choose a
dentist, take time to check your familyís dental care needs. You may want to call the dentist you are considering before making your selection. You are expected to stay with the first dentist you choose for one year. You should not hurry this important decision. You may name a dentist on your Membership subscription or by calling Q-Dent at another time.
4. MEMBERSHIP AGREEMENT STATEMENT: Q-Dent can only deliver maximum benefits to subscribers who stay in the plan for one year or more, since prepaid dental insurance plans do not pay claims like indemnity insurance. The fully prepaid dental services and the partially prepaid dental services that are included in the policy are the benefits the Q-Dent Dental Plan offers to its members. PLEASE NOTE, that under the terms and provisions of the Q-Dent Membership Agreement and the policy that YOU MUST PAY ALL CO-PAYMENTS TO THE DENTIST YOU WILL CHOOSE.
|5. SELECT YOUR PREMIUM PAYMENT MODE
|Premium Payment Mode||One Member||Two Members||Three to Four Members|
By Bank Draft Only
By Payroll Deduction
or Bank Draft Only
|*If more than [four] members add [$20.00] for each additional member.|
6.1 BANK DRAFT: Return the Membership Subscription Application with the first premium payment. Following the first payment, all other monthly premiums will be paid by Bank Draft. Sign the Automatic Bank Check Authorization card. Monthly Individual Premiums:[$56.00, $84.00, $104.00].
6.2 PAYROLL DEDUCTION: Return the Membership Subscription and Payroll Deduction Authorization form to Q-Dent. Monthly Group Premiums - By Payroll Deductions: [$45.00, $65.00,
CLICK HERE FOR MEMBERSHIP APPLICATION