List Each Person to be covered:

Notes:
Social Security Number is required for all adults.

You may only add children up to age 23 if they are in an accredited school and dependant upon you.

Last Name		First Name		Initial		Date of Birth		Sex		SSN#

Street Address	City	State	Zip
Home Phone	Work Phone	Emergency Phone

(Get these totals from proposal.) Use your browsers back button to review the totals

Monthly Premium

Amount due with application

Please choose your preferred payment method:

Visa	Master Card

Billing Address:

Street Address

City

State

Zip

Credit Card No:

Expiration Date:

Monthly Bank Draft  -- Please print this completed form and mail, along with a check for the amount noted "DUE WITH APPLICATION" and an original check marked "VOID", to:

Attention: New Business Department
1525 Merrill Drive, Suite 2000
Little Rock, AR 72211

By my initials below, I hereby formally request approval of my application for dental insurance as completed.  If my application is approved I hereby authorize, American Denticare, of Little Rock, AR to utilize the payment option I have selected and to either charge my credit card or draft my designated checking account for my premiums on approximately the 25^th  of each month for my premiums due for the upcoming month.  I understand that I may cancel my coverage at anytime with a 15 day written notice delivered to the offices of American Denticare.

I hereby agree.(required)

Initials             (required)

Was your enrollment in this dental program prompted by an agent or broker?

Yes

No

If yes, please provide the name and telephone number of the agent or broker so that proper credit may be given. :

Name

Telephone