Massachusetts Delta Dental PPO Plus Premier Plan
UMass Worcester - GSBS Only

ANNUAL ENROLLMENT FORM
2017-2018 POLICY YEAR

The enrollment deadline is midnight on 12/15/17.

Please note that if you purchase the plan now, your coverage will be effective 1/1/18-8/31/18.


DISCLAIMER: The Delta Dental PPO Plus Premier Plan requires a minimum number of enrollments, which we expect to meet. In the event that we do not receive enough enrollments, we will contact you about a refund as well as your other dental insurance options.


TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

To find your ID, go to PeopleSoft, Self Service, Student Center, Personal Information, Demographic Data. You should see your 9-digit ID near the top of the screen.

first name:
last name:
student ID: