Family Care - Plan Enrollment

Please review your application and correct the following validation errors:

Enrollment Application

Basic Information

Contact Information

Mailing Address

Dependents

First Name	Last Name	Relationship to You	Date of Birth

Payment Details

Bank Draft
Credit/Debit Card

Expiration Date

Billing Address

My billing address is different than my mailing address

To process an enrollment at a later date, provide a future date up to 29 days from tomorrow.

Submit

Please review your application and correct the following validation errors:

Please review the information of your application before submitting for approval.

Consent to Electronic Transactions

I have read the Terms and Conditions, I have reviewed my application(s) including the applicant and payment information and confirm that it is correct. I agree that by checking the box and clicking to sign, my agreement and consent will be legally binding and enforceable and the legal equivalent to my handwritten signature.

Full Name

Date Signed

11/21/2024

Enrollment Summary

FL Dental Xtra

Monthly dues$29.95
Enrollment fee $30
FL Dental Xtra Terms & Conditions

Initial Payment

Your initial payment includes your monthly dues plus an additional one-time enrollment fee.

Initial payment$59.95

30-Day Money-Back Guarantee!

If for any reason you are not completely satisfied with our plans, you may cancel at any time within the 30-day period for a refund unless you have subitted a claim.

Select an available provider from your area.

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