The One Individual Dental Plan


You can print a paper application to enroll your client by clicking the brochure/application link above.  However when you become appointed with Fidelity Security Life you can enroll your clients on-line.  To become appointed with Fidelity Security Life, click the Fidelity Security Life Agent application above.

Click here for The Online Application.

Benefits

Choose any Dentist!

Preventive Services -
Class A
100% - UCR
no waiting periods

›› Two routine Exams no less than 6 months apart.
›› Two routine Cleanings no less than 6 months apart.
›› Fluoride (Child to age 16) once per year

Basic Services -
Class B
80% - UCR
6 month waiting period

›› Bitewing X-rays (set of 4) no less than 6 months apart.
›› Fillings
›› Simple Extractions

›› Full mouth x-rays in a 36 consecutive month period.

Major Services -
Class C
50% - UCR
12 month waiting period

›› Endodontics
›› Oral Surgery (Surgical Extractions & Impactions)
›› Periodontics

Major Services -
Class D
50% - UCR
24 month waiting period

›› Crowns, Inlays, Onlays (single restoration)
›› Bridges (treatment must begin after the effective date of coverage)
›› Dentures (treatment must begin after the effective date of coverage
)

Deductibles/Co-Pays

›› $35 lifetime, Per Person - Class A
›› $50 calendar year, Per Person - Class B, C, & D combined
›› $10 per office visit co-pay, Per Person
Miscellaneous ›› Calendar Yr Max. $1000 per insured
›› 12 month rate guarantee
 
ELIGIBILITY: Individuals who are age 18 through 60 years of age, and their eligible dependents (spouse and unmarried children from birth through age 19; through age 23 if the child is a full-time student).
Usual, Reasonable, and Customary Benefits:  Benefits are based on the Usual and Customary fee, as determined by Gerber Life, in the area in which the Dentist practices.
 

Brochure and Application


. Adobe Reader required

View Brochure and Application (Effective September 1, 2009) (PDF: 994k)

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Rates

Rates apply to all States
pdf Adobe Reader required

View Rates (Effective September 1, 2009) (PDF: 462k)

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Fidelity Security Life Agent Contract

Adobe Reader required

View Fidelity Security Life Agent Contract (PDF: 465k)

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Fidelity Security Bankdraft Form

Acrobat Adobe Reader required

View Fidelity Security Life Bankdraft Form (PDF: 32k)

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List Bill Form

Acrobat Adobe Reader required

View List Bill Form (PDF: 16k)

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Assignment of Commission Form

Acrobat Adobe Reader required

View Assignment of Commission Form (PDF: 15k)

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Additional Forms

Click here to view Addtional Forms

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