First Name
Middle Initial
Last Name
Marital Status
Single Married Legally Separated Divorced
Date of Birth
(mm/dd/yyyy)
Gender
   Male Female
Social Security Number
(no dashes, numbers only)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
Create a Username
(Used for later online access)
Create a log-in Password
(Used for later online access)
Effective Enrollment Date 01/01/2026

CHOOSE COVERAGE LEVEL
 SILVER Plan*
  
 GOLD Plan*
The Silver Plan covers 100% of fees for Preventative Dental Services, and 50% of fees for Basic Dental Services.   The Gold Plan also covers 50% of fees for Major Dental Services including Crowns & Crown Repair, Prosthodontics, Dentures, Bridges, Inlays, and Onlays. In addition, coverage is increased to 80% of fees for Basic Dental Services.
Both Plans include 100% Vision Services (up to $150 per year) for Eye exams, single vision, bifocal, trifocal, lenticular, & progressive lenses, elective & medically necessary contacts, and frames.   Same as Silver Plan
* See Coverage Tab for a more detailed list of covererd items, plan details, and plan limits

CHOOSE DEPENDENT COVERAGE

(Select Dependent Coverage and enter dependent information if applicable)

 

I Elect Dependent Coverage For:  None   spouse only   spouse & child(ren)   child(ren) only

 

NAME

 

SEX

 

RELATIONSHIP

 

SSN

 

BIRTH DATE

 

DEPENDENT ONE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

DEPENDENT TWO INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

DEPENDENT THREE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

DEPENDENT FOUR INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

DEPENDENT FIVE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Please Select Method of Payment

Checking Account   Credit Card

Please complete the following if paying with a checking account:

Bank Name:

Name on Account:

Account Type:  

Routing Number:    checkGuide

Account Number:  

 

 

 

 

 

Please complete the following if paying with a Visa or Master Card (we do not accept American Express or Discover):

Name on Account:

Card Number:       (no dashes, numbers only)CV2image

Card CVV Security Code:      

Expiration Month:   Year:

 

This is not standard disclaimer, so please read it carefully:

The premiums for this program are collected in advance of the month that they are due.  Premium must be paid via automatic collection by credit card or bank draft. Your initial premium due will be collected within 5 business days of the application. Subsequent premiums will be collected on the 15th of the month prior to the start of the next month.  There will be no invoicing of premium; premium will ONLY be collected electronically.

You are authorizing Babbitt Municipalities, Inc. (d.b.a. Group Benefit Associates) to draft a checking account or charge a credit card for the purpose of collecting premiums for the Dental and Vision policy.  The act of collecting a premium to your credit card or bank account does not constitute coverage. 

You will receive an ID card within 10-14 business days of your enrollment. 

 

Any data that you submit to Group Benefit Associates through this website will be processed and used as described in the Privacy Policy available at the following link: Privacy Policy. By checking the box to the left, you agree that you have read and understood the terms of the Privacy Policy, and that you are granting Group Benefit Associates permission to use your data in accordance with the terms of the Privacy Policy.