Application Instructions

1. COVERAGE: Complete the information for the person who is subscribing for A Dental Service Contract.

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.

3. CHOOSING A DENTIST: You must choose a dentist who is willing to Issue a Dental Service Contract. All Family Members must use the same dentist you choose. Before you choose a dentist, take time to check your family’s dental care needs. You may want to call the dentist you are considering before making your selection. You are expected to stay with the dentist you choose for one year. You should not hurry this important decision.

4. PLAN RATES: Select the appropriate payment method and rate.

5. 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. You will also need to sign the Bank Draft Authorization form.

6. PAYROLL DEDUCTION: Return the Membership Subscription and Payroll Deduction Authorization form to Q-Dent.