Connection Dental Plus Online Enrollment

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 7 p.m. Central Time.

All fields are required unless marked as optional.

Current or Former Federal Employee, Survivor Annuitant, Overage Dependent of parents' FEDVIP Plan

Email Address

First Name

Middle Initial (optional)

Last Name

Date of Birth

Gender

Male

Female

Enrollee Social Security number

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.

Are you a Survivor Annuitant?

Yes

Phone Number (xxx-xxx-xxxx for U.S. numbers)

Physical Address

Street Address

City

State/Province

Zip Code Please enter a 5-digit Zip code.

Country

Is mailing address different from physical address?

Yes

Mailing Address

Street Address

City

State/Province

Zip code Please enter a 5-digit Zip code.

Country

Employment Information

Federal employment status

Active

Retired

Former

Not applicable

Federal agency where applicant is employed or was employed

If you are not a federal employee, but are eligible due to losing coverage from your parents' FEDVIP plan due to age, please provide the name of your parent (who is either a federal employee, a former federal employee or a survivor annuitant).

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

Civilian

Non-Civilian

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 enroll even if their parent (who is a current or former federal employee, or an annuitant) is not a GEHA member.

Select Coverage Option

If you have additional dependents, please list their full names, dates of birth, genders, relationships and Social Security numbers in the space below: (optional)

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 plan 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.

The name of my Federal Employee Health Benefits (FEHB) plan is/will be:

The three-digit enrollment code for my FEHB plan above: 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?

Yes

What is the name of the other insurance?

What is the effective date of policy of the other insurance?

What is the other insurance phone number? (xxx-xxx-xxxx for U.S. numbers)

Who is the policy holder of the other insurance?

Please list the family members covered by the other insurance:

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, visit https://www.geha.com/plans-and-benefits/dental-plans/connection-dental-plus/connection-dental-plus-premium-pricing

Select Payment Option

Monthly bank draft from Checking or Savings

Quarterly bank draft from Checking or Savings

Quarterly billing from Connection Dental Plus

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.

I decline, please cancel this application

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.

If you have any questions or need assistance with this form, please call us at (800) 793-9335.