Mail-In Dental Enrollment

How Do I Sign up for Dental via the mail?

Please download one of the following applications based on your payment selection. The following payment options are:

  • 1198-1199 payroll deduction form
    Download application and 1199 Form

  • Employee Express deduction form
    Download application and Employee Express Form

  • Authorization for automatic payment a deduction from your personal checking account the 2nd of each month to pay premium for the subsequent month.
    Download application and Bank authorization Form

  • Annual Payment
    Fill out the application form and send it with a check with the full annual amount to the address below.
    Download application Form

  • Forms are in Adobe Acrobat. Click here to obtain the reader so you can view/print the documents.

    Mail Enrollment Forms to:

    Benefits Unlimited Insurance, Inc.
    P.O. Box 530820
    Henderson, NV 89053-9907

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