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My FamilyMyself and my Spouse/Domestic PartnerMy Dependent Child(ren) under the age of 19Myself

SECTION 1 APPLICANT INFORMATION

Last Name:

First Name:

MI:

Social Security No.:

Home Address:

City:

State:

Zip Code:

Birth Date:

Gender: MF

Telephone No.:

Email:

SECTION 2 PLAN SELECTION

BlueDental Choice Plan QF

BlueDental Copayment Plan QF

SECTION 3 – DEPENDENT INFORMATION List all Eligible Dependents to be covered. Eligible Dependents include your spouse/domestic partner and/or children to age 30. Children of a domestic partner may be covered when the domestic partner is also covered.

Do you or any of your dependents have Dental insurance under another Plan?

YesNo

Person’s Name:

Policy No.:

Insurance Co. Name/Address:

SECTION 4 – SUPPLEMENTAL INFORMATION

1. Is the person named in Section 2 a permanent Florida resident?

YESNO

SECTION 5 – PREMIUM PAYMENT METHOD

1. Check Credit Card QuarterlySemi-AnnualAnnual

Premium Payment: $:

2. Bank Draft: MonthlyQuarterlySemi-AnnualAnnual

to make a bank draft of $

From Account No.

Account Nº

Bank Routing No.

3. Credit Card

Cardholder name:

Billing Address:

Credit Card nmber:

Type: —Please choose an option—CréditoDebito

Card: —Please choose an option—VISAMASTERCARDAMERICAN EXPRESSDISCOVER

Expiration Month: —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Expriration Year: —Please choose an option—202220232024202520262027202820292030

Security code:

and to remit the amounts deducted to Florida Combined Life Insurance Company, Inc. (FCL), upon instructions from FCL. The amount of deduction indicated above is approximate and may be corrected as instructed by FCL. This authorization will remain in effect until: (a) I/we cancel it in writing; (b) the above account is closed; (c) the deduction and remittance arrangements between the above financial institution and FCL are discontinued.

SECTION 6 – REPLACEMENT OF COVERAGE

Is this insurance intended to replace ANY dental insurance currently “in force?” YESNO

If “YES” complete the following:

Insurance Company Name:

Policy No.:

Effective Date:

Termination Date:

SECTION 7 – AGENT INFORMATION

Name:

Email:

Phone: