Western Dental Insurance Online Enrollment
Member Services (800) 992-3366

Student Insurance Dental Plans

Please complete this enrollment form in order to sign up for your Western Dental insurance plan. If you have any questions about this process please call (800) 992-3366.

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Miembro Principal
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Provider selection will be auto assigned to a Western Dental office based on zip code entered. Additional providers available after 24 hours of enrollment. 

I hereby authorize Western Dental Services, Inc. (“Western Dental”) to either (a) withdraw the monthly premium from my account on a recurring basis, or (b) withdraw the full amount of the annual premium from my account on a one-time basis (or until satisfied).  This authorization will remain in effect for a minimum of one year and will renew automatically unless (i) my plan is no longer being offered by Western Dental, or (ii) I provide Western Dental with 30-days written notice of my revocation of the authority granted herein.   I understand that the payment amount may vary as a result of change(s) I make once enrolled, such as, but not limited to, adding and deleting dependents, or changes made by Western Dental of which I am notified pursuant to my plan agreement.  I agree that Western Dental’s rights with respect to each such withdrawal shall be the same as if it were a check signed personally by me.  I further understand that should my withdrawal not be honored by my bank, I will incur a service charge for any withdrawal not honored, and my coverage may be terminated as set forth in my plan agreement.

I agree to the Terms and Conditions found in the Evidence of Coverage and Disclosure Form

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