Plan document library
Plan summaries and rates, and group application forms in downloadable .PDF format.
Voluntary group plans
Voluntary group plans
Group application form [9050, 9060 & 9070]
Fillable group application form for voluntary group plans 9050, 9060 & 9070
Voluntary group plans
Group application form [602 & 603]
Fillable group application form for ACA group plans 602 & 603
Voluntary group plans
Enrollment/change form
Enrollment and change form for primary subscribers and dependents in group plans.
Voluntary group plans
Group Electronic Funds Transfer (EFT) form
Set up or change an automatic funds transfer to pay a monthly invoice.
Pooled group plans
Group application form
Fillable group application form for all pooled group plans [9000, 9010, 9020, 2500 & 2525]
Pooled group plans
Enrollment/change form
Enrollment and change form for primary subscribers and dependents in group plans.
Pooled group plans
Group Electronic Funds Transfer (EFT) form
Set up or change an automatic funds transfer to pay a monthly invoice.
SD Retailers Association plans
SDRA plans [8010, 8012, 8013 & 8015]
Overview of benefits and rates for 2021
SD Retailers Association plans
Group application form
Fillable group application form for all SDRA group plans [8010, 8012, 8013 & 8015]
SD Retailers Association plans
Enrollment/change form
Enrollment and change form for primary subscribers and dependents in group plans.
SD Retailers Association plans
Group Electronic Funds Transfer (EFT) form
Set up or change an automatic funds transfer to pay a monthly invoice.
Individual & family plans
Individual & Family Plans [1040, 502 & 503]
Summary of benefits and rates for 2021
Individual & family plans
Enrollment form
Fillable enrollment form for all Individual & family plans [1040, 502 & 503]
Individual & family plans
Individual Electronic Funds Transfer (EFT) form
Update your bank account information for auto-payments for your indivdidual/family plan with this EFT form.
Plan features & options
Prevention Pays flyer for members
A flyer for members describing the Prevention Pays plan feature.
Plan features & options
Prevention Pays flyer for brokers
A flyer for brokers and consultants describing the Prevention Pays plan feature.
Plan features & options
Prevention Pays flyer for employers
A flyer for employers, group plan administrators, and human resources managers describing the Prevention Pays plan feature.
Plan features & options
Health through Oral Wellness flyer for brokers & employers
A flyer for brokers, employers, group plan administrators, and human resources managers describing the Health through Oral Wellness program.
Plan features & options
Health through Oral Wellness flyer for members
A flyer for members describing the Health through Oral Wellness program.
