More Convenient Enrollment

Thank you for using SecureCare Dental's online enrollment. Our secure on-line enrollment form allows SecureCare Dental clients to submit employee:

• Enrollments
• Coverage changes
• Information changes

Employee information submitted on-line will be live in our eligibility system within 2 business days. If you have any questions, please contact us.

An * means that field is a required one that has to be filled in with the requested information.
Qualifying Event
*	Enrollment Event:	Select EventEnroll employeeChange employee coverageChange employee informationTerminate EmployeeTerminate Employee - Add to COBRATerminate Employee - Delete from COBRATerminate DependentChange dependent informationAdd dependent
Employee Information
*	SSN:	- -
*	Last Name:
*	First Name:
	Middle Initial:
*	Position/Division:
*	Date Employee Signed Form:	/  /   (mm/dd/yyyy)
Comments/Notes
Attach Documents You may use this section to attach documents such as a proof of student status, certificate of credible coverage or divorce custody decree. Documents attached will be sent with your email when you click "Submit". Attachments may only have the file extensions: .txt, .jpg,.bmp,.tif or PDF.
Add Attachments
Submit Enrollment Employer must keep original signed enrollment form on file.
*	Enrollment submitted by:
*	Email confirmation to:
*	Group Name:
*	Group #:

back to top