ENROLLMENT FORMS - DENTAL AND VISION CARE
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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 PDF Type Premium
Dental/Vision Application for Enrollment
Dependent Children Ages 22-27 Dental Enrollment Form
Allotment Form 299
Direct Debit Application Form
Dental Claim Form
Vision Claim Form



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