Dental Forms

• SIGN UP ONLINE
  (Online sign up includes online bank authorization)
• Dental Application (pdf)
• Bank Authorization Form (pdf)

The Standard Dental Care - MAX BUILDER

The Standard Dental Care plan includes a valuable feature that allows qualifying plan participants to carryover part of their unused annual maximum.

A participant earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions.

If a plan participant doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year.

Benefit Threshold: $750
Dental benefits received for the year cannot exceed this amount

Annual Carryover Amount: $400
Max Builder amount is added to the following year's maximum

Maximum Carryover: $1,200
Maximum possible accumulation for Max Builder