Primecare Dental Plan Welcome Plan Application Form (Mail only).

To purchase Primecare Dental Welcome Plan please print and fill out the application form below.
(Bolded fields are required)

Contact Information
First Name		Date of Birth (month/day/yr,i.e. 01/15/1975)
_____________________		___/___/____
Last Name		Phone (Res.)
_____________________		________________
MI		Phone (Bus.)
___		________________
Address		E-mail
_____________________________________		_______________________
City		Employer
______________________________		_______________________
State
________
Zip
________
Spouse, Dependent's Info
Spouse's First Name		Last Name
___________________		___________________
MI		DOB (month/day/yr, i.e. 01/15/1975)
___		___/___/____
Dependent's First Name		Last Name
___________________		___________________
MI		DOB (month/day/yr, i.e. 01/15/1975)
___		___/___/____
Dependent's First Name		Last Name
___________________		___________________
MI		DOB (month/day/yr, i.e. 01/15/1975)
___		___/___/____
Dependent's First Name		Last Name
___________________		___________________
MI		DOB (month/day/yr, i.e. 01/15/1975)
___		___/___/____
WELCOME PLAN Info
Select Plan Premium Check appropriate box
Senior		$85
Senior +1 dependent		$135
Individual		$115
Individual +1 dependent		$145
Individual + family		$165
Add annual enrollment fee		$ 10
Grand Total		$______
Comments
__________________________________ __________________________________ __________________________________ __________________________________ __________________________________
Credit Card Info
Payment Method Check appropriate box		Credit Card Number
VISA MASTERCARD DISCOVER CHECK		_____-____-______
Expiration Date (MM/YYYY) ___ /_____

Mail Application to:

Primecare Dental Plan
ATTN: APPLICATION PROCESSING
10604 Trademark Parkway, Suite 310
Rancho Cucamonga, CA 91730

© 2009Primecare Dental Plan. All Rights Reserved.