D.P. Brokers, Inc. - Atlanta, GA

We must receive your completed application by the 15th of any month to begin coverage the first of the following month.

Please fax your completed application to: (770) 650-1592.

Social Security Number
Last Name
First Name
Middle Initial
Birthdate
Sex

Home Address
City
State
Zip Code
Home Phone
	Area Code - Phone Number
Business Phone
	Area Code - Phone Number

List All Your Eligible Dependents Below if They Are To Be Covered

(Eligible dependents include your spouse and/or unmarried children from birth to age 19 or to age 23 if a child is both a full-time student and dependent on you for primary support.)

First

Middle

Last

Sex

Date of Birth

2. Spouse
3. Child
4. Child
5. Child
6. Child
7. Child
8. Child

Coverage Effective Date	Dental Facility Number
Agent Code Number	Plan Code Number
Number of Dependents Covered	Contribution Amount $
For Office Use Only Amount Paid $	Enrollment Fee $

I wish to enroll in the Plan. I understand that this is a minimum one year contract and that all necessary dental services will be provided as described in the schedule of benefits which I have received and understand.

Date:
Applicant's Signature:
Agent Signature:

Enrollment Instructions

1.	Complete the attached application. (Be sure to list all family members to be included.)
2.	Select your payment mode. a. If monthly, complete the authorization for deduction with full bank information and sign the lower portion. (Be sure to enclose the first month's payment and a blank voided check, plus the enrollment fee of $35.00.) b. If annual, choose Visa or Mastercard or payment by check. Fill out bank card section and send no money, or enclose your check for the full annual payment, plus enrollment fee.
3.	Monthly bank draft: Monthly pre-authorized bank draft administrative fee: $1.00. Annually Visa/Mastercard, check, or money order: $0.00.
4.	Mail all information (and check payable to CompDent Corporation, if applicable) to us.

Note: Completed applications, with correct payments, received by CompDent by the 15th of the month will become effective on the first of the following month.

Please Note: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against in insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

You may cancel this contract within the first 30 day of coverage.

Authorization for Deduction - Signature Required

Name Social Security Number
I authorize
to make a monthly bank draft (drafted on the 15th)
deduction of $ + $1.00 administrative fee = $ .
My checking account number (monthly only).

and to remit the amounts deducted to CompDent (CD) upon instructions from CD. The amount of deduction indicated above is approximate and may be corrected as instructed by CD. This authorization shall cease (a) upon my giving written cancellation notice to you; (b) automatically upon my termination as an employee, member, or depositor, as the case may be, of the above-named organization; (c) automatically upon termination of my checking, savings, or share account number above as this authorization relates to such an account; or (d) upon discontinuance of the deduction and remittance arrangements between the above-named organization and CD. I understand this authorization does not waive or change any of the payment provisions of any policy issued to me by CD and if this authorization terminates for any reason, any further payments required under said policy(ies) shall be made as provided in the policy(ies). I agree that the above-named organization is acting gratuitously and for my sole accommodation and not as an agent for CD.

Date Signed Signature X

Bank Card Selection:
For your convenience: (Choose One)
Card Number: (Fill in card number.)
Expiration Date: (Month/year.)

Amount Charged: (Must be the enrollment fee + the annual contribution.)
$

I hereby authorize charging my bank card.
Cardholders Signature: X
Date:

Contribution Rates +

Monthly Bank Draft +
(If Applicable)

One-Time Enrollment Fee

1 member	$9.50	$114.00
2 members	$16.00	$192.00
3 Members	$22.00	$264.00
4 Members	$27.00	$324.00
5 or More Members	$32.00	$384.00

$1.00 administrative fee monthly for pre-authorized bank draft.
(Waived if paying annually.)

$35.00

Hours: Monday - Saturday 9:00 am - 5:00 pm

D.P. Brokers, Inc.
312 South Atlanta Street • Roswell, GA 30075
(678) 461-7990 • (800) 942-2148 • Fax: (770) 650-1592
Contact Us at: mjay@mindspring.com

[ Welcome ] [ Pre-Paid Legal Plans ] [ DHMO Dental Plan ] [ CompDent Dental Application ]

Copyright © 1999 All Rights Reserved.
Intelligent Media Ventures, Inc.