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Get United Concordia Dental Enrollment Form

Each month, coverage will become effective the first day of the next month. For applications received after the 20th day of the month, coverage may not become effective until the first day of the second month. I understand that I am responsible for full payment of any dental services provided prior to the effective date or after the cancellation date of the policy. (See Section F on back of form for important information.) Date: Sponsor's Signature: Because personal information is being reque.

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