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Dental Forms

We recently updated our forms and applications. Please select the link for the applicable benefits in which you want to enroll and complete the application. If you are enrolling in Life Insurance and Disability Income benefits you must also complete the Life Insurance and Disability Income (LIDI) Metlife Enrollment Change form.

Enrollment Forms:

Dental Benefits Plan Enrollment Application Only - For enrollment period of October 1-31 of every Plan Year

Annuity Plan Membership and Other Benefits Form - For enrollment in the dental plan or other benefit plans outside of open enrollment

Dental Benefits Plan Summary:

2022 UCC Dental Plan Schedule

Claim Forms:

Member Submitted Dental Claim Form