Forms

AlwaysDental Individual Plan:

• AlwaysDental Enrollment Form

• AlwaysDental Schedule of Benefits

• AlwaysDental Cancellation Form

• AlwaysDental Change of Address Form

• AlwaysDental Checking Account / Credit Card Change Form

• Claim Form

Cypress Employer Group Dental Plans:

• Cypress 1000 Plan Summary

• Cypress 1500 Plan Summary

• Cypress 2000 Plan Summary

• Employee Group Dental Roster Enrollment Form*

• Employer Group Dental Application

• Employee Group Dental Enrollment Form

• Claim Form

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

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

Forms for Agents:

• Commission Agreement

• Agent Questionnaire

• Form W-9

Submit all above items with a copy of your current insurance license and a $50 appointment fee payable to Cypress Dental Administrators (this will share the cost of appointment and background check fees for one agent).

Mail to:

Cypress Dental Administrators
7510 Shoreline Drive, Suite A-1
Stockton, CA 95219

Forms for Agencies:

• Agency Agreement

• Business Associate Agreement

• Commission Agreement

• Agent Questionnaire (for at least one agent affiliated with agency being appointed)

Submit all above items with a copy of your current agency insurance license, current copy of agent license and a $100 appointment fee payable to Cypress Dental Administrators (this will share the cost of appointment and background check fees on both an agency and one of its agents).

Mail to:

Cypress Dental Administrators
7510 Shoreline Drive, Suite A-1
Stockton, CA 95219