InsuranceCompany.com - Golden West Dental Insurance, California dental plan for individual and family

Step ...
Buy Your Dental Plan

There is no waiting period for your dental services to begin, pre-existing dental conditions are covered and best of all, the dental plan services starts the next business day, so you can see the plan dentist immediately.

After you complete the online dental application we will send you an email confirmation as your temporary proof of application with instructions on how to make your first dental appointment without your id cards. Be absolutely sure your email address is correct once you have entered it.

If you experience any difficulty during the application submission process, you can always print the completed application and fax it to us at 310-534-4344. Please complete the dental application TODAY so we may process your request immediately. If you have any questions regarding the Aetna dental access plan please contact our office for assistance.

First Name:
Last Name:
Mailing (Billing) Address:
City:
State:
Zip Code: Example 90001
Phone Number: Example (310)555-1212
Fax Number: Example (213)555-1212
E-Mail Address:
Your Enrollment Information
How Many Members Are You Enrolling:
Any Dependents
Your Social Security # Example 111223333 No Dashes-Spaces
Your Date of Birth MM/DD/YYYY Example 10/15/1950
Sex

Please Type Upper-Lower Case Letters	Spouse/Other Information	Child #1 Information	Child #2 Information	Child #3 Information
First Name
Last Name
Social Security # Example 111223333
Date of Birth MM/DD/YYYY Example 10/15/1950
Sex
Marital Status

( ) Individual Dental Plan - $80 annual:

Individual Membership: You have selected the Aetna Dental Network Access with DentaChoice⁺ - Individual - $80 Annual - Bank Check Option: NBBI, the administrator for this plan will debit your bank checking account $80 for one year dental coverage plus a one time $15.00 enrollment fee (non refundable) which equals a total of $95 for your payment.

( ) Family Dental Plan - $130 annual:

Family Membership: You have selected the Aetna Dental Network Access with DentaChoice⁺- Family - $130 Annual - Bank Check Option: NBBI, the administrator for this plan will debit your bank checking account $130 for one year dental coverage plus a one time $15.00 enrollment fee (non refundable) which equals a total of $145 for your initial down payment.

Name of Your Bank:

Your Next Check Number:

Enter the numbers from the bottom
of your check as illustrated below:

Bank Routing Code Bank Account Number

Your Driver's License Number:

Your Driver's License State

The schedule is only to be used as a guide to determine approximate prices for dental services in the geographic area noted. The fee schedule amount reflects average fee information currently available on the Aetna Dental Access system. Individual dentist fee schedules may differ. We make no guarantee as to the accuracy of any particular fee amount. In order to determine the specific rates for a dental provider, you should contact the dental provider directly.

Dentists participating in the program network have agreed to make certain dental services and supplies available to you on a �discounted service� basis. The term �discounted service� means a dental service that is available to you at a reduced cost from fees normally charged by the dental provider and for which you are solely financially responsible. All payments to dental providers are due and payable at the time of service, unless another payment arrangement is mutually agreed upon between you and the treating dental provider. You shall be subject to the treating dental provider�s late payment and other office policies.

THIS PROGRAM IS NOT AN INSURANCE PLAN and we do not make payments directly to healthcare services providers. It is a discount program and you are obligated to pay for all healthcare services at time of service. You will receive discounts for healthcare services from those providers who have contracted with the plan. This plan is administered by National Benefit Builders, In. (NBBI), 248 Columbia Turnpike, Florham, NJ 07932. The program and its administrators, AccessOne Consumer Health, Inc. have no liability for providing or guaranteeing service or the quality of service rendered. For questions or complaints contact them at 8 Villa Road, Greenville, SC 29615 or at the website www.accessonedmpo.com. Note to Utah residents: This program is not protected by the Utah Life and Health Guarantee Association.

AGREEMENT AND AUTHORIZATION

I/We have read, understand, and agree to the terms and conditions above. I authorize the dental plan administrator and/or assignees limited power of attorney to charge my credit card according to the dental plan I have selected. I further authorize them to charge my credit card for all future annual renewals as they come due. I will notify them in writing of my wish to cancel the membership 30 days in advance. You may use the dental discount referral service according to the Member Information Guide and Membership Identification Card(s) which will be mailed to you shortly after your purchase.

If you agree to these terms and conditions

Please press the Submit Button ONLY ONE TIME
Wait a few moments for your online confirmation

This is not an attempt to describe the product services and its' contents but merely used as a sales tool for the purpose of product illustration. The website and its' owners cannot make recommendations as to whether any illustrated product may meet the users' particular needs. Therefore, the suitability of the product is the final determination of the user of this website. The use of this website is acceptance of the sites' privacy statement. Services is not in effect until an application is signed, transmitted, payment received and approved by the underwriting company unless otherwise specifically stated. A physical and/or background inspection may be done to verify the information provided. The quote(s) will be based up on the underwriting information you supplied and the quote(s) is/are subject to change upon inspection and review by the underwriting company. The underwriting company reserves the right to determine the final payment, services and acceptability If you have any questions regarding the information collected, please contact the agency. All quotes are provided by DEL AMO Insurance Services, Inc,. DBA: InsComp Insurance Services and/or one of it's affiliated agents, brokers, agencies, brokerages, and/or companies Lic: 0B93601 Agent David Blunt, Lic: 0638553. Commercial use by others is prohibited by law. No portion of any news or information from this website may be photocopied, faxed, mailed, distributed, transmitted, published, broadcasted, duplicated, or re-distributed in any manner for any purpose without prior written authorization of its' owner.