California Application for Dental Insurance

Select the method of payment for your initial and ongoing/subsequent payments.

Payment and Billing Method Definitions

Easy Pay - Electronic Funds Transfer (EFT): The premium amount will be withdrawn from your bank account using the account information provided below.
Credit Card: The premium amount will be charged to a credit card using the account information provided with this application.
eBill: Available for ongoing monthly payments only. You will receive a monthly email notification at the email address provided on this application reminding you to pay your monthly premium on the online payment portal, where you will be able to select your payment method.

1. Select Initial Premium Payment Method (First Month)

The initial payment will be collected upon processing the application.

Credit Card Payment

2. Select Ongoing Monthly Premium Payment Method

No paper or electronic monthly billing statement will be issued for automatic EFT and Credit Card payments.

eBill - Individual Monthly Payment

Today 08/08/2023, you are scheduling a one-time payment of $29.25 to be debited from your bank account and recurring automatic EFT payments of $29.25 to be debited from your bank account on or after the 1st day of each month.
I authorize the Company (Cigna Health and Life Insurance Company) to make premium withdrawals, in the amount of the premium payment noted above, from my bank account as identified on this form and authorize the banking facility (Bank) to charge such withdrawals to my account. This authority will remain in effect until the Company receives written notice from me that the authority is terminated. Such termination will be effective with respect to the next premium due following 21 days after the written notice is received by the Company. I understand that if for any reason, a withdrawal is not honored by the Bank (including, but not limited to, insufficient funds or my direction to the Bank not to honor the withdrawal) my health care contract premium will be unpaid, and failure to pay my health care contract premium may result in termination for my health care contract, and that this authorization will remain in place until cancelled and that any due or past due premiums may be withdrawn under this authorization. I understand and agree that termination of this authorization does not relieve me of responsibility for charges incurred under my health care contract. I agree to indemnify and hold harmless the company and its affiliates and employees for any claims arising out of transfers or deductions from my account in accordance with this authorization.

Today 08/08/2023, you are scheduling a one-time credit card payment of $29.25 and recurring automatic credit card payments of $29.25 to be debited on or after the 1st day of each month.

Today 08/08/2023, you are scheduling a one-time EFT payment of $29.25 to be drafted from your bank account and recurring automatic credit card payments of $29.25 to be debited on or after the 1st day of each month.

Today 08/08/2023, you are scheduling a one-time EFT payment of $29.25 to be drafted from your bank account. For ongoing premiums, you will receive an electronic monthly bill (eBill) at the email address provided in this application and are responsible for initiating monthly payments of $29.25.

Today 08/08/2023, you are scheduling a one-time credit card payment of $29.25 and recurring automatic EFT payments of $29.25 to be drafted from your bank account on or after the 1st day of each month.

Today 08/08/2023, you are scheduling a one-time credit card payment of $29.25. For ongoing payments, you will receive an electronic monthly bill and are responsible for initiating monthly payments of $29.25.

- You will be notified by mail when payment amounts change. Cigna may also cancel this authorization if a debit is returned unpaid.
- Once submitted, the initial payment request cannot be cancelled.
- If you wish to cancel the recurring payment or if there are changes to your account information, please call the customer service number listed on the back of your ID card during normal business hours at least 4 business days in advance of the payment date.

Account Holder Agreement

By checking the box below, you confirm that:

a. You are the account holder and agree the one time policy premium may be deducted from your bank account or credit card as shown above.

b. You agree to the terms and conditions of this authorization and approve the recurring monthly premium payment as shown above.

c. You agree this payment may be processed by a third-party vendor on behalf of Cigna.

Your payment has been canceled. Your account was not charged. Please try again by selecting the “Continue to Payment” button, or save your application and try again later. For assistance, call Cigna at 877.244.6215, 8:00am-8:00pm ET Mon-Fri.

Page Context

SAD

Medicare Supplement Insurance Quote

Cigna Supplemental Insurance Quote

Application for Dental Insurance

Individual and Family Dental Plan Quote

Medicare Supplement Insurance Application

Cigna Supplemental Insurance Application

Your Progress

Billing Information

California Application for Dental Insurance

Select the method of payment for your initial and ongoing/subsequent payments.

Payment and Billing Method Definitions

Account Holder Agreement

INDDENTCA1120v1 941252 11/20 ©2020 Cigna This application is not proof of coverage.

Page Context

1-877-895-4619

7 Days a Week

8:00 am - 8:00 pm ET

1-877-895-4619

1-877-895-4619

7 Days a Week

8:00 am - 8:00 pm ET

VIEW STATE DISCLOSURES, EXCLUSIONS & LIMITATIONS

VIEW STATE DISCLOSURES, EXCLUSIONS & LIMITATIONS

INDDENGN1120 941251 11/20 ©2020 Cigna This application is not proof of coverage.