Superior Dental Care Secure Form
Use this form to enroll employees in your group's SDC plan.
EMPLOYEE ENROLLMENT FORM
Which dental plan are you enrolling?
General Information
Company Name:
Effective Date of Action:      
Employee Name:
Group #:    Subgroup #: 
Address: 
 
City:  State: 
Home Phone #:  Alt. Phone #: 
Zip:  County: 
Date of Birth:   SSN: 
Email: 
Reason for the Form  
/ :
/ Date:  
:
:
Plan Enrollment
DentalVisionFull NameRelationshipGenderBirth Date (MM/DD/YYYY)Other Dental Insurance
 
 
 
 
 
 
If enrolling in the SDC-Kids Plan, please check here (groups 50 or less):  SDC-Kids Plan
Other Dental Coverage (if you selected 'Y' in the Other Dental Coverage section above for any of the dependents listed, please complete this section):
Are you, your spouse, or any dependents also covered under another dental policy?    If yes, please complete the following:
Policy#:
Employer Name: 
Insurance Company: 
Employer Address: 
SSN:   Birth Date:   
City:  State: 
Individuals covered: 
Zip:  County: 
Superior Direct Connect - Once your group is enrolled and effective, go to www.superiordental.com, click on Get Connected! and sign up to access your account and personal benefit information.

Notice: Any person obligated for any part of a pre-payment may cancel such agreement within 72-hours after having signed the agreement or offer to enroll. Cancellation occurs when written notice of cancellation is given to SDC or its agents or other representatives.

On behalf of myself and any dependents listed above, I hereby apply for coverage under the Master Group Contract issued to my employer by Superior Dental Care. I understand that the benefits for which I (we) will be eligible are in accordance with those described in the Master Group Contract and any changes provided therein. I understand that certain services may require a co-payment payable by me (or my dependents) directly to the provider of such services. I further understand that covered services may be obtained through any licensed dentist and also that certain services may require a co-payment payable by me (or my dependents) directly to the provider of such services. Superior Dental Care also offers a network only plan. Please refer to the dental contract available through your employer for clarifications on the dental plan currently in place. I authorize my employer to deduct the necessary dental service fees, if any, from my wages or salary, with the understanding that he acts as my agent in all dealings with Superior Dental Care and that all acts performed by him and all notices given to him in such dealings are binding upon me, as not prohibited by statute or regulation. In the event that this Application for Coverage is accepted, I authorize my dentist to give, upon request, any information concerning the condition or treatment of any person included under such coverage whenever such information is considered necessary by Superior Dental Care for the proper disposition of a claim submitted for payment or in fulfillment of obligations imposed on Superior Dental Care by state or federal statutes. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Authorization
By entering my initials in the box below, I certify that all information submitted is accurate and current.
Initials:      Name of Person Completing Form:      Email: