 PROFESSIONAL LIABILITY CONSULTING SERVICES, INC 24 South Broadway, Tarrytown, New York, 10591 Phone: (914) 366-9000 Fax: (914) 366-0700 Dental Plan Application (Plan 504 - 500 Series) |
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Download Application as Adobe Acrobat file Download Adobe Acrobat Reader |
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| Choose Plan: | Includes $10 processing fee. | |||||
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Dependent Information (Only List Covered Individuals) |
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I understand the terms and conditions of the dental plan and agree that any dental procedure which is performed by an non-participating dentist will not be covered under the dental plan. In addition, all membership rates and fees will be fully earned by the company with no refunds. I understand that the fully completed (signed/dated) original application and total amount due must be received by PLCSI no later than the 20th of the month prior to the month for which coverage is to be effective. Coverage will be effective on the 1st of the month. |
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Subscriber's Signature X_______________________________ Date: ______________ Please print out and sign your completed application and mail it, with your check made payable to: PLCSI - 24 South Broadway, Tarrytown, NY 10591 |
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