Classic Dental Plans

Welcome to the StarsDental Online Application System. This system will automatically determine the appropriate plan (Applicant Only, Applicant + Spouse, Applicant + Child(ren), Applicant + Family) according to the information you enter on the following pages.

By submitting your application using this form, you hereby apply for coverage under Group Dental Insurance Policy Form GH-1112 issued to the Voluntary Group Trust. You also certify upon submission that you have read the applicable Fraud Notice contained within this web site. (You will be given a chance to read these fraud notices near the end of this application process in the "Payment, Options,and Agreements" section.)

To begin the application process, please fill in the information below, then select one of the buttons at the bottom of this page to indicate what information you'd like to enter next.

Primary Applicant Information
Primary First Name: Primary Last Name: Birth Date (mm/dd/yyyy): Gender: MaleFemale Social Security Number: Phone (xxx-xxx-xxxx):	Address Line 1: Address Line 2: City: State: Zip: Email:
Spouse's Information
Spouse First Name: Spouse Last Name: Birth Date (mm/dd/yyyy):	Gender: MaleFemale Social Security Number:
Dependent 1's Information
First Name: Last Name:	Birth Date (mm/dd/yyyy): Gender: MaleFemale
Dependent 2's Information
First Name: Last Name:	Birth Date (mm/dd/yyyy): Gender: MaleFemale
Dependent 3's Information
First Name: Last Name:	Birth Date (mm/dd/yyyy): Gender: MaleFemale
Dependent 4's Information
First Name: Last Name:	Birth Date (mm/dd/yyyy): Gender: MaleFemale
Dependent 5's Information
First Name: Last Name:	Birth Date (mm/dd/yyyy): Gender: MaleFemale
Critical Illness
In the past 2 years, had any Proposed Insured used tobacco (cigarette, cigars, pipe, snuff, chewing tobacco) or nicotine patches, nicotine gum or any other form of nicotine? Yes No Has any Proposed Insured ever been diagnosed as having or been treated by any member of the medical profession for AIDS, for AIDS Related Complex (ARC), or of any disorder of the immue system, or tested positive for the Human Immunodeficiency Virus (HIV)? Yes No In the last 5 years, has any Proposed Insured been diagnosed or received medical advice for cancer, leukemia, melanoma, malignant tumor, Hodgkin's disease or non-Hodgkin's lymphoma? Yes No In the last 5 years, has any Proposed Insured been diagnosed as having or been treated for or consulted a licensed health care provider for: 1. Stroke or transient ischemic attack (TIA)? Yes No 2. Diabetes? Yes No 3. Disease or disorder of the heart or blood vessels, heart attack or uncontrolled high blood pressure? Yes No 4. Kidney failure or abnormal kidney function? Yes No 5. An organ transplan or been advised of the need of an organ transplant? Yes No
Credit Card
Card Number: Card Type:	Name on Card: Expiration Date:
Bank Checking Account Information
Bank Name: Routing Number: Account Number:
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