Dental Plan Option for Lafayette College Students

UNITED CONCORDIA FLEX PPO DENTAL PLAN
Spring 2018 Policy Period Enrollment Form


The enrollment deadline is 12/15/17. Any student who enrolls from 11/16/17 to 12/15/17 will be effective as of 1/1/18. 


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)