209-478-4808

800-350-3989

Forms for Employers

* Employer has the option to either fill out an Employee Roster Enrollment Form or an official Employee Group Dental & Vision Enrollment Form for each employee.  Both forms of enrollment are not required.


All group dental and vision applications may be faxed or emailed to Cypress Ancillary Benefits.  Initial premium check payable to “Cypress Ancillary Benefits” is required to be mailed in before processing of a group enrollment can take place.