National Plan Enrollment Form Step 1 of 2 - Member Information 50% Complete the entire application which begins below and be sure to include all eligible dependents (family members you wish to include under your coverage) Upon successful acceptance of your application, your plan will become effective the first of the following month. Gender*MaleFemaleDate of Birth*Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Month123456789101112Day12345678910111213141516171819202122232425262728293031First Name*Last Name*Street Address*Apartment #City*State*AlabamaCaliforniaDistrict of ColumbiaGeorgiaIllinoisIowaKentuckyMichiganMinnesotaMississippiNebraskaNew JerseyNew MexicoNorth DakotaSouth CarolinaTennesseeWest VirginiaWisconsinWyomingZip Code*Email* Home Phone*Dentist NameHow did you hear about us ?*Select OneAgentDentistE-HealthEmailSearch Engine (Google, Bing, Yahoo, etc.)FacebookTwitterReferralOtherOther*AgentsAccount HouseAcevedo MarisolAdam SaheedAdcock MichaelAdelusi HenryAgency LLC Mai InsuranceAgreda JhonnyAgudelo Guerra OscarAhern KeriAhlers ChristopherAlexander DawnAlexandre BedlieAlford AnthonyAli FazalAlmonte RitaAlvarez LuzAlvarez GriseldaAmador FelixAnderson KristenAnderson ShireeAnderson RobertAndre DavidAnthony TonyAntonneau HeatherArana MariluAraque MarisolArata SilArbolaez JospehArias DonnaArriaga AdelfaArteaga GiomarArteaga GiomarAssociates PNRAtwood SusanAvital-Cohen AyeletAwad MohammedAxe StephenAyers RandyBabcock VincentBahr JasonBaird JeremyBaker GlenBaker SherriBaker VondolynBalakrishnan Girija SarikaBaldwin LowryBall TimothyBallard DanielBandy-Alms BarbaraBanks GeorgeBarbone MichaelBarnes SteveBaron RonBarreto CharlesBarrineau ThomasBarrlentos JoseBarrow ValerieBartlein RandallBartley DavidBarton MichaelBastardo RafaelBaste JorgeBateman WilliamBauer MaryBean AnnBeckman BarbaraBedsole SidneyBeebe KennethBelcher StevenBell MarieBell RuthBellinger JeffreyBenavides DianaBendtsen GeorgeBendtsen GeorgeBenson AlanBentley DanielleBenton GwendollenBerg BrianBerrios ManuelBerry ThomasBerry GeraldBetz- Bender JaniceBeyerlein BradleyBhatt SaurabhBielak JarekBiltis JackBlack ShamekaBlanco AngelicaBlizman DonnaBlizman DonnaBlocker II AnthonyBlunt DavidBoer GeraldBoice JasaenBonaparte BarbaraBooth NeilBowen NicoleBowen RichardBozanich SamBradley GeoffreyBraun MitchellBraun JayBrent A. J.Bress AllenBress AllenBridges AngelaBrooks LouisBrown JesseBrown DonaldBrown CatherineBrown ChantelleBrowne CarolineBrowning BrettBruce RobertBruckman AdamBrunet MigdaliaBuffano PhilipBullerman LindaBurke Bridges ToniBurkett JamesBurnett DemarcusBurns CynthiaBurrows JamesBurton MichelleBushey RichardBushko HeidiBustinza JessicaButler BrianCadet CarlCallahan DanaCallan JamesCalvin MicheleCampbell JayCannella JosephCapehart GeorgeCariglio PaulCarmenate JeannieCarr WilliamCarrasquillo JavierCarroll CharlesCarter JulieCarter Jr CharlesCasimir JeanCastrillo AliCastro CarlosCavin DennyCedeno YusetCelestin DaraChacon CesarChaffin HollieChalmers JohnChang LeilaChang FredCharles EnocChecca MathewCherry CarolChickk KennethChristianson JasonCiko JohnClark JeffreyCleveland JohnClifton SteffanieCobb PaqueseCode BrianCode JordanCoggins BarbaraCohen CathyColey EsmieCollazo VirmarieCollins Peggycom Dentalinsurance.Condon AngelaConnelly JohnCook DawnCooley DustinCoradin GraceCorcoran JulieCorominas WandaCostello RichardCoursey JessicaCova Figueroa JesusCovert DougCox AndrewCraig RebeccaCram NormanCrawford OliviaCretella ElizabethCrews BryanCrews BryanCrook SandraCross TimothyCurrier ClaytonCuster JohnDacre PaulDahlquist AmyDaidone FrancisDanco ThomasDarnell BenjaminDaugherty ScottDaul KellyDavis LoNeaseDavis LarrieDavis LarrieDaza LuisDe Alba FelipeDe Moya AngelicaDedmon LarryDee ScottDeegan DarleneDega BridgettDeitemeyer TimDelahanty MartaDelatorre CaraDelatorre CaraDenHouter JoyDeSouza AnthiaDeters RobertDetweiler JoniDeVoe AshlyDiaz HectorDiaz AdrianaDickinson GeannineDilling GregDillow DavidDiRaimo RobertDissault DanDMD Dr WelchDO NOT USE DO NOT USEDoerges DavidDoering RobertDoherty FrankDonnelly TimothyDonovan StevenDoran RobertDoss KarenDr Angelov Dentique DentalDr Bivens DA Sun CityDr Burchell - Dr Weinstock DHSDr Carter DA Plant CityDr Cohrn and Pellosie Heritage DentalDr Cowan Cosmetic DentistryDr Duvart & Desinor Bright NowDr Fellner Lake Wales DentistryDr Fox Palm Tree DentalDr Georgy Ideal DentistryDr Mueller DA TampaDr Parasher Caring DentistDr Phelps Caring DentistDr Ruiz Crown DentalDr Walker - Hsu DHS NorthdaleDr Weber Family Dent HernandoDr Weiner DA New TampaDr. Almerico Woodside DentalDr. Kulangara Smile Design LithiaDr. Monticciolo Family DentistryDr. Monticciolo & Fares Family DentistryDr. Parikshak Premier DentalDr. Walker and Vu DHS WestshoreDuczak GeorgeDuever JamesDuff KassandraDuffy TimothyDuke LoydDunne LaurenDuperval VeroniqueDuque LuzDurango ElsimarDurrell NatashaDuval NadineDzurick CarrieEarp JeremyEck GregoryEdouard StevensEdwards CarolynElder PhilipElliott BrandonEmery KarenEmery TimothyEmpert RichardEnnis EthanEpstein PeterErd LisaErnest CynthiaEscudero GinetteEvers ChristianeFalcon MichaelFebres GuillermoFeliciano LuisFeliciano CarlosFernandez LizetFerris AllynFessler CaseFinkbeiner DennisFinnestad MatthewFiorella JohnFisher JohnFlores HelenFloyd SheilaFolb PaulitaFoldenaur JohnFord JeffreyForeman StevenFoster TiffanieFraher GerardFranco SalvadorFranco AngelFranco AlbaFranzoni JeffreyFraser DennisFrederique CherlyFreiman ArnoldFrierson JamillaFuchs CurtisFullwood DeborahGannon JosephGannon ArleneGarcia BarbaraGarcia WilliamGardner CraigGarofalo JosephGearhart MarkGecewicz WilliamGibbons GeorgeGibson EricGiles JohnGilford WilliamGill AndrewGill JaniceGill JaniceGinopolis PeterGionis StephenGiuffra JamesGjestland NormanGjika EneaGoff BrendaGoheen DavidGoldberg FrankGoldfield IraGoldsmith AllenGomez FelixGomez Riveros LuisGonda DawnGonyou ChristopherGonzales MabelGonzalez AnnieGonzalez NathanaelGonzalez JackelineGoon DonaldGoon DonaldGosline ClaudiaGossage Jr JohnGrant JamesGreen GabrielGreen CoraGreenbaum JohnGrigoriadis KathrynGroup HylantGrullon MariaGuenst KennethGuerrero ClaudiaGuerrero BettyGuerriero RobertGullickson DarrylGupta SeemaGutierrez GloriaHaass DavidHack ElizabethHaeger CarlHagen ThomasHager WilliamHamilton RobertHamilton MaryHamrick LarryHaney DanielHaney danHanke BradleyHarting GailHartzler RyanHasegawa HiroshiHatcher GregHayden MarkHayes ShawnHealth Group MCCHecht JoeHegarty JasonHeggland GillHeller LeonardHemming MaureenHenderson WalterHenkel JonathanHenry DonnaHenry FrancisHernandez CharlesHernandez RigobertoHernandez DorisHernandez DorisHernandez AntoniaHernandez RobertoHernandez-Melgar NidiaHerr AndriaHerring-Albritton CarolynHicks BrianHidalgo LauzauthHilaire RonyHill ConstanceHill SharleneHindsley CherylHoeneisen RayHolley SharonHolmes WillieHonkomp JoleneHorace AnneHornacek StevenHorner AlanHoskinson LauraHotvedt AngelaHouck DarrenHouck JillHowes DaleHuamanchumo HugoHullinger MatthewHumpal JessHursey Jr PrestonHusk CarolynInsurance ZimzoomInsurance Marketing AtlasIsrael StevenJackson NevilleJackson MichaelJames GregoryJares MarkJarrett OwenJayne RichardJean FarrahJean WilfridJean Francois FrankyJean-Jules DivensonJean-Paul DonnaJefferson QuintinJefferson AcquindolynJenkins AlanJenkins GeorgeJennewein LizJimenez MariaJoffrion JefferyJoglar-Gaya JoseJohnson 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JamesLeon RoodnyLeon RoodnyLesher DonaldLevy EstherLewis DawnLeyva NancyLichtenfels RyanLiedtke SabraLinares LarryLinderman WilliamLindstein AdamLinkin JamesLinnemon RonLittle WallaceLlinas-Ochoa ManuelaLluch IrmaLobdell DeborahLoCicero MichelleLogan ShanesiaLombardi LucindaLombino FrankLonardo RobertLong BillyLongo JosephLopes MarcioLopez CarlosLopez JoseLores Parra NorvenLoThamer TerryLoustaunau JoaquinMacchione AnthonyMacDonald LaurieMachado GabrielaMahoney ThomasMajersky JohnMandino AndrewMannello DanielMaras TedMarcano HenryMarkese DanielMarona MichelleMarquez MyrnaMarrullier MarshaMarsh BrianMartens DavidMartin JerryMartin LukeMartinez MarilinMartinez VictorMartinez ShelbyMartinez OrquideaMartinez-Perez JanetMassrock JacklynMatalucci GaryMateo ZoraydaMathwig RogerMatos WandaMaurice ChristopherMaxson CarlMay ScottMay CathyMayer ThomasMayer AshleaMazzapica, Jr PaulMcCarthy WilliamMcCauley JamesMcClellan LarryMcCurdy PaulMcDade MarkMcDowell FrederickMcGhee MelissaMcIntyre JohnMclaren MichelleMcNeely StephenMcNorton EdwardMefferd AndrewMehler DavidMejia GuerlineMena Martinez Jose LuisMendez IsaacMenendez FrancisMenne JamesMercado JeffreyMerchant JeffreyMercier BlendyneMeredith MichaelMerz CathyMesser RoyMesser McQueen CrystalMeyers JasonMiedema JustinMilagros RitaMiles ChristopherMiller AngelaMiller TammyMiller CliffordMiller CindyMilligan TimothyMilligan TimothyMilonas ThomasMinkler AllenMitchell BrooksMitchen JenniferModglin RichardMogollon MariaMoncarsz AlanMoncell WayneMonfred DominicMonroe RobertMonteblanco JayMontermini DavidMontero RoqueMoreno ChristineMorgan JordanMorin ThomasMorrel JesseMoses JosephMosley JulieMoya WilliamMulvey RichardNadolski LawrenceNagel DavidNash JefferyNazaire GertyNazariego NaylibethNeal DiannaNess GregNess JerryNgo LyNguyen MaiNichols ToshaNicou ChristosNoel TimothyNolan AndrewNoreen DennisNucete NedelsonO Brien JillO Carroll JamieO Hara ThomasO Neill BradleyO Sullivan KevinO Sullivan ShawnOberlin DanielOcampo LidicisOey 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CarlosQuigley ElizabethQuire TysonRabinowitz ArnoldRamentol AlfredoRamirez RaulRamos IvonneRandazzo JamesRange DennisRatchford Robert (Andrew)Rayfield JohnReagin ThomasReckner MichaelRedmond MarciReichmann RichardReiff DeborahReimann AmyReyes SandraReyes SandraReyes Zuniga DorisRhoden-Porcenat NyalaRhodes RickRice JamesRice OrlinRichardson Robert ScottRider FredericRieger RichardRingoen ToddRink MonteRios AvelinaRitter MichaelRivera VilmaRoach AngelaRobert Hurley EHealthRoberts DanielRoberts BlakeRoberts JulieRobinette MichelleRobinson MarkRodriguez FernandoRodriguez JorgeRodriguez MarcelaRodriguez MonicaRodriguez YaneisyRodriguez MilitzaRodriguez CarlosRogachevsky EileenRoig Martinez RaydelRojas OscarRoller DeniseRollinson WilliamRomeo SamuelRomeus YvesRorem HollyRosenkrantz HowardRothsman WallaceRousmaniere DaleRowe BrianaRowe CharlieRuby JeffreyRucker EricaRucker EricaRuiz RosemaryRukstele AnthonyRumple LucasRusche BarryRusso JamesRuth RobertqRuthstrom ScottRyan JacquelineRyckis DonovanSackett BrianSaidi MondherSaidi Ben (Mondher)Saintillien JamesSakamoto WayneSaland LeslieSalas MargaritaSalgado ClaudiaSalmAon CecilSamuelson LuAnnSanchez AbelSanders PatrickSandford Jr JohnSands BarclaySanon ErickSantiago KarenSantonelli GayleSaportas JosephSara ReginaScaglione JackSchake RamonaSchermerhorn PhilipSchmidt JohnSchreppel GayleSchroeder NathanSchumacher VictorSchumaker HaroldSchumer RobSchwartz NeilSegarra DanelisSeivers TimSeivers TimothySemacio LeoSenior RoderickSenson ArnelSepulveda LourdesSerna RodolfoSerrano VitaliaSheldon AdamSherman JanSias NikkiSilver DavidSilvey JoshSimeon ElizabethSimmons TeresaSineno Jr JosephSisic VildanaSkinner RogerSkinner DougSlayton RobertSmith GarySmith RobertSmith WilliamSmith WilliamSmith EricSmith JerrySmith StephenSmith StevenSmither BradleySnider BrendaSnowman CatherineSnyder MarkSollner RichardSorensen PeterSorg PaytonSoriano RicardoSousa IvonneSpeichinger AlisonSpinuso GabrieleSpotts JenniferStaebler MichaelStaggs RonnieStagliano KerryStambler Dr. SilviaStarke EricSteinman JamesStephens MichaelStephenson JosephSteve Test Steve TestStevens JamieStevenson RobertStiller TiffanyStingone LisaStoffer Jr. JamesStonehill JoyStoner JohnStoute AlexisStracener MarvinStraubel MercedesStrawbridge JaneStrehl RichardStrelow JodiStrijewski AlexStrong BiragoStruckhoff AdamSullivan ChristineSullivan DavidSumrall ErnieSunderman TimSutherland RobertSwink JamesTapia-Rosa JoseTaylor DavidTaylor RobertTaylor CarolynTemeyer StephenTeran Ruiz JoseTest TestTest TestTest TestThaxton JosephThe Villages Smile DesignThomas LelandThomas SuzanneThomas AlexThomason LarryThompson DedrieThornburg ClydeThornhill ThomasTomecko JosephTornes LuisTorres HugoTownsend DwayaneTownsend MariaTrabal GlendaTrail DawnTrakys VaidotasTurbay MariaTurner BryanUnger MartinUpdyke JeffreyUrban MaryUrena Delvalle OfradisUrquia WalterUrrea WilliamVadovsky KylaVan Iseghem KerryVance HerschelVander Kooi DanielVane NatividadVargas LuisVasquez FrancisVasquez Castro BelkysVega RichardVelieri SusanVentolo GerardVermaak SteveVertich MarkVetere TammyVice SpencerVidair RichardVidal NikkiVidal-Curtis ChariVillamarin SaraVillota AlexandraVimond FrederickVinokur MitchellViti EsterVogel PeterVolosin CharlesWages MelanieWait DelosWalton BrendaWareheim JamesWashington LennyWashington AlvinWatkins FrankWatts KevinWeidner JamesWerner JohnWest NenaWestbury LarryWestbury LarryWestlund RichardWestlund RichardWhaley BeverlyWheeler ScottWhidden RobWhite RosaWhite PerryWhite LatoyaWhittington RobertWichman MatthewWike DeniseWiley YvonneWilkerson KellyWilkinson EugeneWilliams ClaudetteWilliams ChristopherWilliams MaquitaWilliams-Von Zopf JeanWilliamson LindaWillmore RebeccaWinters JeffreyWohlberg MelissaWojan DieterWokasch MelissaWolf PatriciaWolff MichaelWood RandyWoodburn TheodoreWortham CarolWright III AlbertWurstle CarrieWysocki TimothyYancent EgmaYeates EricYeutter CatherineYihdego AsterYoung BradyYoungblood DavidYoussef EliasYoussef EliasZaid DannyZanghi GaryZimmerman HowardZiskie GerardZito GregSource*Select OneRX AdvantageSearch EngineWebsiteE-HealthTBTFacebookeBayDentistOtherDependents: Eligible dependents include your spouse and /or unmarried children from birth to 19 years of age, or 25 years of age if a full-time student or fully dependent on you for support. National Plan Certificate of Coverage Member Guide I am applying for dental coverage and by my initials below, I understand this dental plan is a (1) year non-refundable program. I authorize the dentist who has rendered services to me or members of my family to make available to Argus Dental & Vision my dental records, photocopies or information regarding such services to the extent permitted by law. If information is not complete and your signature is not present, the application will not be processed. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.By placing my initials in the textbox, I constitute this as my online signature :* Individual Rates Value Standard Preferred Individual $9.94 $18.95 $27.94 Individual & Spouse $19.89 $37.89 $55.87 Individual & Child(ren) $25.32 $48.22 $71.12 Individual & Family $38.74 $73.78 $108.83 *For monthly billing, your account will be debited or charged by the 15th of each month for one month’s premium plus a $1 monthly service charge. NOTE: A $35 one-time enrollment fee applies to your first year of enrollment which includes the $3 NCOA membership fee. Coverage Type*IndividualIndividual + SpouseIndividual + ChildrenFamilyPlan Type*ValueStandardPreferredBilling Frequency*MonthlySpouse Information*First NameMiddle NameLast NameDate of BirthGenderMaleFemaleChildren Information*First NameMiddle NameLast NameDate of BirthGender MaleFemale National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 National Plan - Value Price: $0.00 National Plan - Standard Price: $0.00 National Plan - Preferred Price: $0.00 Enrollment FeeThis is a one time enrollment fee. Price: $35.00 Total Billing Today for National Plan $0.00 Payment Type*CardEcheckCredit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name eCheck Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type By clicking the button below, I authorize Argus Dental & Vision, Inc. to charge my credit card or bank account for the initial payment plus enrollment fee, if paying monthly I also authorize a charge on the 15th of each month for the monthly premiums plus a $1 monthly service fee. Review and Submit {all_fields}