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Florida Affordable Insurance SafeGuard Dental Insurance SUBMISSION REQUEST FORM
Your Name
Street Address
City State Zip Code
Day Telephone Number
Evening Telephone Number
Best Time To Call
Your Email
Comments

Florida Dental & Vision Insurance

SafeGuard Dental & Vision Insurance
Tegric Dental & Vision Insurance
Tegric Vision Insurance
Discount Dental & Vision Insurance

Florida Dental & Vision Insurance SafeGuard Application

SafeGuard Florida Dental Plan Enrollment Form (Florida)

Step 1: Your Information

Last Name:
First Name:
M.I.:

Social Security Number:

Home Address:
Address Line 2:
City (complete name):
State:
Zip Code:

Sex:
Male:
Female:

Date Of Birth:

Month:

Day:

Year:

Day Time Phone Number:

Email Address:

Plan Selection

THIS MUST BE COMPLETED TO ENROLL IN PLAN:

*Use This Link To Find A Dental Facility Near You: [ Click Here ] Enter your choices below**
Facility Number 1st Choice:	Facility Number 2st Choice:
*Make sure you choose two general dental offices (facilities) for every person you are enrolling. The second choice is a backup, just in case your first choice is unable to accept new members at this time.

Step 2: Your Family's Information

Family Member: Spouse
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 1st Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 2th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 3th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 4th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 5th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 6th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Family Member: 7th Child
Sex: Male: Female:	Name: First Name: Last Name:	Date Of Birth: Month: Day: Year:	Disabled: Yes: No:

Step 3: Payment Information

Coverage Type

CLASSIC CHOICE I am enrolling (choose one)

Myself Alone:
$8.00 + *$20.00 = $28.00

Monthly - Subscriber & One Dependent:
$15.75 + *$20.00 = $35.75

Monthly - Subscriber & Family:
$23.00 + *$20.00 = $43.00

Yearly - Subscriber Only:
$94.44 + *$20.00 = $114.14

Yearly - Subscriber & One Dependent:
$186.00 + *$20.00 = $206.00

Yearly - Subscriber & Family:
$271.68 + *$20.00 = $291.68

PREMIER CHOICE I am enrolling (choose one)

Myself Alone:
$11.99 + *$20.00 = $31.99.00

Monthly - Subscriber & One Dependent:
$22.50 + *$20.00 = $42.50

Monthly - Subscriber & Family:
$33.00 + *$20.00 = $53.00

Yearly - Subscriber Only:
$141.60 + *$20.00 = $161.60

Yearly - Subscriber & One Dependent:
$265.68 + *$20.00 = $285.68

Yearly - Subscriber & Family:
$389.76 + *$20.00 = $409.76

*Includes a one time setup fee of $20.00

Select Your Payment Method:
Monthly Bank Draft:	Monthly Credit Card Draft:
Annual Check:	Annual Credit Card:

Billing Address:
Billing Address Line 2:
City (complete name):
State: Zip Code:

Pay by Automatic Bank Account Draft

Account Type:

Bank Name:

Branch Routing Number: The first 9 digits on the bottom of your check

Account Number: up to 17 digits on the bottom of your check

Pay by Credit/Debit Card

Select Card Type:

Credit Card Number:

Expiration Date:

Month: Year:

CCV * The last 3 digits on the back of your card:

Authorization: By submission of this application for health benefits, I authorize SafeGuard Health Enterprises, Inc. to debit the above-indicated bank account for the annual payment as noted. I understand that my bank account will be debited on or about the 15th of each month for the following months coverage. I also confirm that I have reviewed the plan documents presented on this site and agree to the Terms and Conditions as indicated in the Disclosure also found on this site.

If your application and payment is received by the 10th of the month, you will be able to use your benefits on the first day of the following month. (e.g. received by March 10, your benefits will be effective April 1. After the 10th of March, your benefits will be effective May 1.)

Your Electronic Signature - Type Your Full Name: I agree to the Terms and Conditions
Month: Day: Year:

Please make sure that you check all your answers before submitting the form. If any errors are found you will be contacted by either email or phone and processing of your application will be delayed.

[Click On A Link Below For More Information]

SafeGuard Dental & Vision Insurance
Tegric Dental & Vision Insurance
Tegric Vision Insurance
Discount Dental & Vision Insurance

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Florida Affordable Insurance SafeGuard Dental Insurance

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Florida Dental & Vision Insurance SafeGuard Application

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SafeGuard Dental Insurance