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Dental Insurance Forms

All of forms on this website are in PDF format. If you do not have Adobe Reader, download from www.adobe.com. Click on the form you want and print or save it to your computer.

Guardian - Traditional / DMO	Aetna DMO - 2011
Policy Booklet	Highlight Sheet
Highlights - 2012	Claim Form
DMO Fee Schedule - 2012
DMO Orthodontic Benefits
Enrollment/Change
Claim Form
Dental Provider Finder

We use two different dental insurance companies and therefore have two different plans to choose from. Again, you are eligible for coverage on your first day and need to return the completed enrollment form to me within 30 days of your start date.

Summary of Benefits– shows a breakdown of the main points of each plan to help you choose which one is right for you. More specific information can be found in the policy booklets.

Young Adult Enrollment Page

Guardian Dental – www.glic.com

Enrollment Form – Complete the following sections:

About Yourself -
     • Name
     • Date of Birth
     • Social Security Number
About Your Dependents (For Family Coverage)
     • Name
     • Date of Birth
     • Social Security Number
Choose Your Coverage - select
     Option 1 - Prepaid DMO*
     Option 2 - PPO (Traditional)
*For Prepaid DMO, list dental office number for each person, sign and date at the bottom