Terms and Conditions: I wish to enroll in the plan I have selected. I authorize and agree to account deduction of the required premium.
This authorization will remain in effect until the financial institution has received and has had reasonable time to act on a written request from me to terminate this agreement. I understand that I can stop a withdrawal by notifying the financial institution at least three business days before the withdrawal is made. In the event of a withdrawal error, I must promptly notify the financial institution to preserve any rights I may have. Please direct billing inquiries to Dental Select, 5373 S. Green Street., 4th Floor, Salt Lake City, UT 84123. I have read and understand the statements above pertaining to the billing option. Your cancellation will be effective the first day of the month following the month your written request is received.
Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
In the event there are insufficient funds when a draft is charged to my account, I agree to pay $25 NSF Fee. The 3rd returned check in any 12-month period will result in the immediate cancellation of my policy. Dental Select reserves the right to deny me the ability to be reinstated on any personal Dental Select plan for two years.
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