New Certificate Numbers — October 1, 2020
Effective October 1, 2020, you have been assigned a new certificate number for claims purposes. Eligible Plan Members will receive new wallet cards with the new certificate number.
It is very important that you and/or your dependents present this new card to your dentist on your next visit on or after October 1, 2020. They will require the new information to submit your claims directly to the Plan.
Any claim you submit for reimbursement to the Plan will need to have your new ID/Certificate number on the claim form.
You can fill in all these forms directly on
the web by typing in the appropriate spaces. Then just print
the form, sign where necessary, and send to the Plan
You need Adobe Reader for these forms to work.
If you do not have Adobe Reader you can download it by
clicking on the link below.
Extended Health Benefits Claim Form (223 KB)
Weekly Income Benefits Claim Form (104 KB)