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Dental Forms

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application.

Enrollment Forms:

Dental Benefits Plan Enrollment Application Only - For enrollment period of October 1-31 of every Plan Year

Annuity Plan Membership and Other Benefits Form - For enrollment in the dental plan or other benefit plans outside of open enrollment

Dental Benefits Plan Summary:

2022 UCC Dental Plan Schedule

Claim Forms:

Member Submitted Dental Claim Form