Dental Plan Option for Lafayette College Students

UNITED CONCORDIA FLEX PPO DENTAL PLAN
2018-2019 Policy Year Enrollment Form


The enrollment deadline for coverage effective September 1, 2018 through August 31, 2019 is August 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)