Enrollment Kit - liberty dental plan (dental)
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This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines LIBERTY Dental Plan’s case submission requirements.
Complete DHMO Group Application 2019
Complete Census Enrollment or Enrollment Forms, available in English or Spanish
First month's premium made payable to LIBERTY Dental Plan
NOTE: All forms must be submitted to Word & Brown: accountmanagement@wordandbrown.com
Dual Option
LIBERTY DHMO plan options may be offered standalone or dual choice with Ameritas W&B $100 Plus PPO Dental Plan(s). Groups can offer up to two (2) LIBERTY plan(s), with a minimum of two (2) employees in each plan, and minimum of three (3) enrolled in Ameritas PPO plan(s). NOTE: separate billing
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful or older documents, please refer to the Forms database.