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Connection Dental Plus Online Enrollment Form

Thank you for your interest in Connection Dental Plus. You can enroll online by completing the following information. If you need assistance with enrollment, please call us at (800) 793-9335 Monday-Friday from 7 a.m. to 5:30 p.m. Central Time.

*Indicates required information

Current or Former Federal Employee or Survivor Annuitant
By providing your email address, you agree to receive email news and information from GEHA. You have the ability to opt out from within any email communication you receive from GEHA.
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Date of Birth
Gender
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(No dashes. Example: 123456789) This information is for enrollment purposes only. To protect your privacy, Connection Dental Plus will issue you a unique Dental ID number for benefit purposes.
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Are you a Survivor Annuitant?

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(No dashes. Example: 123456789) This information is for enrollment purposes only. To protect your privacy, Connection Dental Plus will issue you a unique Dental ID number for benefit purposes.
(xxx-xxx-xxxx for U.S. numbers)
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Physical Address
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Is mailing address different from physical address?

If "Yes," complete the Mailing Address section below. If "No," then skip down to Employment Information.
Mailing Address
Employment Information
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Federal employment status


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If you are employed with the U.S. military, please indicate

Coverage

Please select coverage option and enter information for your spouse or dependent children, as applicable. Connection Dental Plus eligible dependents are your legally married spouse and each unmarried child who is under age 26. Eligible dependents can be enrolled only if the federal employee or annuitant enrolls.

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Are you married?

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Dependent Spouse Information

(Complete this section if applicable. Otherwise, skip down to the next section.)

Date of Birth
Gender

(No dashes. Example: 123456789)
Dependent Child 1 Information

(Complete this section if applicable. Otherwise, skip down to the next section.)

If applicable
Date of Birth
Gender

Relationship

(No dashes. Example: 123456789)
Dependent Child 2 Information

(Complete this section if applicable. Otherwise, skip down to the next section.)

Date of Birth
Gender

Relationship

(No dashes. Example: 123456789)
Dependent Child 3 Information

(Complete this section if applicable. Otherwise, skip down to the next section.)

Date of Birth
Gender

Relationship

(No dashes. Example: 123456789)
Dependent Child 4 Information

(Complete this section if applicable. Otherwise, skip down to the next section.)

Date of Birth
Gender

Relationship

(No dashes. Example: 123456789)
Additional Dependents
FEHB or Additional Plan Information

Connection Dental Plus is a supplemental dental plan and will pay last after other coverage. Please provide the name of your current FEHB and any other coverage information (if applicable). If you have waived FEHB coverage, please enter WAIVED in this field. If you are a former Federal Employee no longer eligible for FEHB, please enter FORMER in this field.

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This information can be found on your FEHB plan ID card or the front of the plan brochure.
Do you, your spouse or any other eligible dependent(s) have medical/dental coverage, other than the FEHB plan listed above?

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What is the effective date of policy of the other insurance?
(xxx-xxx-xxxx for U.S. numbers)
Payment Options

Please select how you will pay for your Connection Dental Plus coverage. After reading and accepting the terms and conditions below, please press Submit to send us your application. Please allow us one to two weeks to process your application and mail your ID cards. Your Connection Dental Plus coverage will not begin until the first of the month following receipt of your premium payment.

Monthly Premium: To view the current premiums, click Connection Dental Plus Premium Pricing.

Select Payment Option


If you selected Monthly or Quarterly bank draft by Checking or Savings, please submit a completed Bank Draft Authorization Form.

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Effective Date of Coverage
Your coverage will be effective the first of the month following receipt of your completed application and premium payment. If you are requesting a later effective date of coverage, what month do you want coverage to begin?
Agree to Terms
I have read and understand the information below and hereby apply for Connection Dental Plus coverage for myself and my eligible dependent(s), if any. The information provided by me on this application is true and correct to the best of my knowledge.

The Connection Dental Plus plan is neither offered nor guaranteed under the contract with the FEHB program. You must notify Connection Dental Plus of any enrollment changes. Your payroll office will not notify Connection Dental Plus for you. Benefits are subject to plan provisions, limitations and exclusions. Please read the Connection Dental Plus Plan Brochure carefully as deductibles, waiting periods and maximum limits do apply.
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