Discount Dental


Check All That Apply          

 -  Single Group Rate - payroll deducted $9/month
 -  Family Group Rate - payroll deducted $12/month
 -  Single Discount Dental Program - home billing $108/year
 -  Family Discount Dental Program - home billing $144/year
* no monthly billing available without payroll deduction

* = required field
First Name: *
Last Name: *
Address: *
City *
State: *
SSN:  *
Employer Name *
Employment Start Date:
Phone: *
Household Members: (excluding applicant)
Family Member #1:
Family Member #2:
Family Member #3:
Family Member #4:
Family Member #5:
Family Member #6:
Family Member #7:
Family Member #8:
Only complete the section below if your employer does not utilize payroll deduction
Name on credit card:
Credit card type:
Credit card number:
Expiration date:

Benefits include a discount dental and prescription drug program.

This is not insurance.
This program contains a 30 day cancellation policy.
Form #45214-A  



New Benefits, Ltd.

14240 Proton Road

Dallas, TX  75244

Your membership is effective upon receipt of membership materials.

This is NOT insurance nor is it intended to replace insurance. This discount card program contains a 30 day cancellation period. The plan is not insurance coverage and does not meet the minimum creditable coverage requirements under the Affordable Care Act or Massachusetts M.G.L. c. 111M and 956 CMR 5.00. This plan provides discounts at certain healthcare providers for medical services. This plan does not make payments directly to the providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization. For a full list of disclosures, please click here. | Limitations, Exclusions and Exceptions | Discount Plan Organization: New Benefits, Ltd., Attn: Compliance Department, PO Box 803475, Dallas, TX 75380-3475.


Discount benefits not available in KS, UT, VT or WA.