liberty dental plan

Enrollment Kit - liberty dental plan (dental)

X

0

Forms Selected

Email

Download

Download Forms & Documents

You've selected 10 Form(s). Choose your download option from the button below.

Form Name
Carrier
State
Group Type
Effective Date

Email Forms & Documents

Share 10 Selected Forms. A single email will be sent to all listed recipients. You can also send a copy to yourself.

Form Name
Carrier
State
Group Type
Effective Date

Form Name

Effective Date

Last Updated

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.