Dental Claim Form
This form is for use for Plan Participants who have dental coverage through their employer's plan. Please take this form with you on the first visit to your dentist. The dentist will likely copy the form and keep it on file for future visits. The dentist will usually file the form directly to The Employee Benefit Service Center.
Click here for a Printer Friendly version of this form which will open in it's own window.
Print the form to your own printer. Note: Adobe PDF Reader is required to view this file correctly. You may need to adjust the size (percentage of enlargement/reduction) of the image, depending on your printer's configuration, to make the form fill the page properly.
