COBRA
Continuation Election Form for groups with 20
or more employees.
Click Here

Cal-Cobra
Notice of option to elect continuation for
Group Dental Coverage with 2 - 19 Employees
Click Here

Renewal Period Coverage Changes
Description of allowable changes.
Click Here

Explanation of Premium Statement
An explanation of your premium statement.
Click Here

RFQ (Request for Quotation) Checklist Form
Click Here

 

Madison National/DHS Forms

Employer Master Application
Group Employer Application
Click Here

Employee Enrollment Form (English)
Individual Employee Application
Click Here

Employee Enrollment Form with VISION (English)
Individual Employee Application
Click Here

Employee Enrollment Form (Spanish)
Individual Employee Application
Click Here

Employee Enrollment Form with VISION (Spanish)
Individual Employee Application
Click Here

Verification of Eligiblity Form (IHC) (English)
Click Here

Madison National Underwriting Guidelines
Click Here

Security Life/DHS Forms

Employer Master Application
Group Employer Application
Click Here

Employee Enrollment Form (English)
Individual Employee Application
Click Here

Employee Enrollment Form (Spanish)
Individual Employee Application
Click Here

Security Life Underwriting Guidelines
Click Here

Sun Life Financial Forms

Employer Master Application
Group Employer Application
Click Here

Employee Enrollment Form (English)
Individual Employee Application
Click Here

Sun Life Financial Underwriting Guidelines
Click Here



DHS Forms (DHMO Only)

Employer Master Application (DHS - DHMO Only)
Group Employer Application
Click Here

Employee Enrollment Form (English/Spanish) (DHS - DHMO Only)
Individual Employee Application
Click Here

Employee Enrollment Form with VISION (English/Spanish) (DHS - DHMO Only)
Individual Employee Application
Click Here
 

Domestic Partnerships

If you have Dental Health Services (DHS) DHMO
Please select the Following:
- Amendment to DHS Agreement - domestic Partner Policy
     (Employer to Complete)
- Affidavit of Domestic Partnership.
To Download These forms...>> Click Here





PROVIDER NETWORKS

Dental Health Services (DHS) DHMO Provider Listing
Below is a link to the most current listing.
Click Here

Madison National - First Dental Health (EPO/PPO) Provider Listing (CALIFORNIA ONLY)
Below is a link to the most current listing.
Click Here

Madison National - Dentemax (EPO/PPO) Provider Listing (NATIONAL NETWORK)
Below is a link to the most current listing.
Click Here

Security Life - Dentemax (EPO/PPO) Provider Listing (NATIONAL NETWORK)
Below is a link to the most current listing.
Click Here

Security Life - PPO USA (PPO) Provider Listing
Below is a link to the most current listing.
Click Here

Sun Life Financial - First Dental Health (PPO) Provider Listing (CALIFORNIA ONLY)
Below is a link to the most current listing.
Click Here 

Vision Plan of America (VPA) Vision Provider Listing
Below is a link to the most current listing.
Click Here