Affordable Dental Plans

I belong to an organization know as the Dental Cooperative and we have a Dental Benefit Plan for groups of any kind. If your employer doesn't offer dental insurance this plan will allow him to provide you a dental benefit without any additional cost to him or his employees. It is also available to any group such as homeowners group, apartment complexes, condominium groups, just about any group you can think of. If you are part of a group that could offer this plan, fill out this form and we will help you set it up. If you aren't sure,fill out the form and we will contact you and answer any questions you have. The Dental Cooperative will handle all the explaining for you.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Please note that all fields followed by an asterisk must be filled in.
Group/Business Name*
First Name*
Last Name*
E-Mail Address*
Street Address
City
State/Prov
Zip/Postal Code
Home Phone*
Business Phone