New Group Enrollment Forms:

• Employer Group Dental & Vision Application

• Employee Group Dental & Vision Roster Enrollment Form*

• Employee Group Dental & Vision Enrollment

• Employee Group Termination/Change Form

• Dental Claim Form

• Group Premium ACH Authorization Form

• Dental Provider Nomination Form

* 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.

Appointment Forms for Agents:

• Broker/Agency Appointment Paperwork
• Broker Dental Commission Schedule
• Broker EFT Authorization Agreement

Submit the above item with a copy of your current insurance license.

Mail to:

Cypress Ancillary Benefits
7510 Shoreline Drive
Stockton, CA 95219

Appointment Forms for Agencies:

• Broker/Agency Appointment Paperwork
• Broker Dental Commission Schedule
• Broker EFT Authorization Agreement

Submit the above item with a copy of your current agency insurance license and a copy of a current agent license.

Mail to:

Cypress Ancillary Benefits
7510 Shoreline Drive
Stockton, CA 95219