Which dental plan are you enrolling?
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If enrolling in the SDC-Kids Plan, please check here (groups 50 or less): SDC-Kids Plan
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Superior Direct Connect - Once your group is enrolled and
effective, go to sdc.superiordental.com
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.
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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.
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By entering my initials in the box below, I certify that all information submitted is accurate and current.
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