THE POLICY PROVIDES DENTAL BENEFITS ONLY.

Dental Plus of Oregon

Form No. 2121D-OR(1/19)Agreement Form No. 2121-OR(1/19) This discount dental plan is provided by Willamette Dental Insurance, Inc.

Personal care for your individual needsWillamette Dental Insurance, Inc. is pleased to offer you Dental Plus of Oregon, a cost saving dental discount plan. This plan gives you simple access to quality dental care at a reduced fee.

Routine and preventive services are provided at 25% savings. Orthodontia is available for both adults and children at a 15% reduction on usual fees. Members do not need to fill out or submit any claim forms.

As a member, you simply schedule your appointments, see the dentist and pay charges at that visit. Willamette Dental Group, P.C. dentists make access to quality dental care easy, while Dental Plus of Oregon keeps that care affordable for you and your family.

Dental Plus of Oregon is not insurance. Plan members must pay for all dental and ancillary services, but will receive a discount on eligible services from Willamette Dental Group providers.

With more than 50 Locationsthroughout the Pacific Northwest, we’re likely to have an office in your neighborhood.

Oregon

Washington

Idaho

To receive discounted dental services, services must be received from a Willamette Dental Group provider and all charges must be paid in full at the time of the visit. Visa, Mastercard and Discover are accepted. Membership must remain continuous during the full treatment period to receive discounted services.

An advance appointment is required to receive care. To schedule your dental appointments, call our Appointment Center at 1.855.4DENTAL (433.6825), Option 1. When you speak to a Willamette Dental Group representative or arrive at the dental office for your appointment, simply identify yourself as a Dental Plus of Oregon member. You will then receive discounts on your quality dental care.

Most dental offices are open Monday through Friday, 7 AM to 6 PM, and occasional Saturdays.

Oregon Locations

• Albany• Bend• Corvallis• Eugene• Grants Pass• Lincoln City• Medford• Portland Metro (multiple)• Roseburg• Salem – Lancaster• Salem – Liberty• Springfield• Tillamook

Southwest WA• Vancouver - Hazel Dell• Vancouver - Mill Plain• Longview

For specific dental office addresses and driving directions, please visit willamettedental.com

For Appointments and Member Services, please call:

1.855.4DENTAL (1-855-433-6825)

Annual Membership Fees

Membership fees may be paid by credit card, check or money order.

How To Enroll

To enroll in Dental Plus of Oregon, simply complete the application form and submit it along with payment of membership fee. The application and membership fee payment must be received by the 25th of the month preceding the period for which membership is to be effective.

You must be at least 18 years of age and a resident of Oregon. Eligible family members include your legal spouse or domestic partner and your unmarried dependent children through age 18 and through age 23 if the child is a registered full-time student at an accredited educational institution. You may not be enrolled with Willamette Dental insurance coverage.

If you are not yet a member and have questions about Dental Plus of Oregon, please call our sales team at 855-998-2273, Option 2 or visit us on the web at: willamettedental.com

Discount SummaryServices must be received from a Willamette Dental Group provider to receive discounted services. Please check with your Willamette Dental Group, P.C. provider for charges on specific treatment.

You will receive a 25% discount on Willamette Dental Group general dentist services, including:

• General exams• Cleanings• Fillings• Crowns

You will receive a 15% discount on Willamette Dental Group specialist or denturist services, including:

• Orthodontia• Oral surgery• Pediatric dentistry• Periodontics (gum & bone problems)• Endodontics (root canals)• Dentures

www.WillametteDental.com

Willamette Dental Insurance, Inc. 6950 NE Campus Way, Hillsboro, OR 97124

Single Membership $179.00Double Membership $358.00Family Membership $454.00

Self (Last, First, Middle Initial) Social Security Number Gender

Mailing Address City/State/Zip Home Telephone Number

E-mail Address Date of Birth

Requested Effective Date

Form No. 2121D-OR(1/19)

Willamette Dental - Dental Plus of Oregon Application Form

Willamette Dental Insurance, Inc. 6950 NE Campus Way, Hillsboro, Oregon 97124

Please print or type. Shaded areas are for producer or office use only.

I’m filling out this application because I am...1

My premium payment will be paid by...3

I want to enroll my...4

Legal Spouse or Domestic Partner (Last, First, Middle Initial)

Date of Birth Gender

Social Security Number

Dependent Child (Last, First, Middle Initial) Date of Birth Gender

Social Security Number

Dependent Child (Last, First, Middle Initial) Date of Birth Gender

Social Security Number

Dependent Child (Last, First, Middle Initial) Date of Birth Gender

Social Security Number

Please continue application on back...

M F

M F

M F

Husband/WifeDomestic Partner

My information is...2

M F

M F

Account Number: Effective Date:

Pay Commissions To: Producer Agency Producer or Agency Name:

Producer or Agency Address: Producer or Agency Phone Number:

a new applicant applying for: (select box below) Single membership Double Membership Family Membership

Personal Check Money Order Credit Card (Visa, MC, Discover) Credit Card Number: Expiration Date: CDC (3 digit security code): Signature: Date:

I hereby apply for membership in the discount dental plan, Dental Plus of Oregon, offered through Willamette Dental Insurance, Inc. for myself and all listed family members. I acknowledge that Willamette Dental Group reserves the right to change membership fees and provisions of the Membership Agreement. I understand that payment of membership fees shall be deemed acceptance of the terms of Membership Agreement. I agree to advise Willamette Dental Group of any change in status within 30 days from the date of change. To the best of my knowledge, the information I have provided in this application form is true and complete. If I choose to sign this application by typing my name below, I acknowledge and agree that my typewritten signature has the same legal effect as my written signature on this application.

_______________________________________________________ Applicant’s signature:

Date: _______________________

Mail this completed application and your membership payment to: Willamette Dental Insurance, Inc. Dental Plus of Oregon 6950 NE Campus Way Hillsboro, OR 97124

You can also email or fax your completed application to: wd.ind@willamettedental.com or 503-952-2679.

Make checks payable to: Willamette Dental Insurance, Inc.

Agreement

Summary of Exclusions

The following services are not eligible for a discount through this plan: Services provided by a provider other than a Willamette Dental Group provider. | Services received before the effective date, prior to cancellation for a full refund, or after the termination of membership. | General anesthesia, including conscious, intravenous and moderate sedation | Hospitalization charges | Dental treatment not performed in a Willamette Dental Group office. | Cosmetic dentistry. | Dental treatment which your Willamette Dental Group provider determines to be unnecessary. | Charges by any person other than a licensed dentist, licensed denturist, or licensed hygienist. | This plan does not coordinate benefits.

Please refer to your agreement for a complete description of terms, conditions and exclusions.

willamettedental.com