Dental Plan Option for Lehigh University Students

UNITED CONCORDIA FLEX PPO DENTAL PLAN
Spring 2019 Policy Period Enrollment Form


The enrollment deadline for coverage effective January 1, 2019 through August 31, 2019 is December 15, 2018.


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
social security number: *
student ID: *
date of birth: * (MM/DD/YYYY)