For information or dental quotes please contact:
Joanna S. Jungen, Group and Broker Manager
205.343.1246 phone
205.343.1239 fax
205.409.2532 alternate fax
866.839.5308 toll free
jjungen@southlandnational.com 		Acrobat You will need Adobe Acrobat Reader
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Group Enrollment Forms

  1. **NEW GROUP CHECKLIST**
  2. **DENTAL TRANSMITTAL FORM**
  3. **GROUP DENTAL MASTER APPLICATION**
  4. **DENTAL Enrollment/Change Application**
  5. **"NOMINATE YOUR DENTAL PROVIDER" FORM**
  6. **Group VisionChoice Master Application**
  7. **VISIONCHOICE ENROLLMENT/CHANGE APPLICATION**
  8. **"NOMINATE YOUR VISION PROVIDER" FORM**
  9. **DENTAL QUOTE REQUEST FORM**
Dental Agent Appointment Forms
  1. **DENTAL AGENT APPOINTMENT INSTRUCTIONS**
  2. **DENTAL AGENT APPLICATION**
  3. **BROKERAGE AGREEMENT**
  4. **Investigative Report Release**
  5. W-9 form