ENROLLMENT FORMS - DENTAL AND VISION CARE

Dental and Vision Care Program forms:

NOTE: Employees of FBI, USSS, DEA, ATF, CBP, CIS, and ICE must complete the SAMBA Payroll Allotment Form 299. All other agencies must complete the Direct Debit application.

Form Description

Fillable PDF

Dental/Vision Enrollment Form

Dependent Children Ages 22-27 Dental and Vision Enrollment Form

Allotment Form 299

Direct Debit Application Form

Dental Claim Form

Vision Claim Form