Confirm Your Plan Details

Review your information and make sure it is correct.

After reviewing, enroll by clicking the button near the bottom of the screen.

< Back to Enrollment Information

Lia Darwn Mollica

Birthdate i :: 10/21/1974

Sex :: Female

SSN :: 0718 View

Address :: 175 W Valencia Rd Apt

154 Tucson AZ 85706

Email il :: runbug2002@yahoo.c

om

Phone :: 949-***-****

Effective i :: 04/01/2023

PRIMARY APPLICANT

By checking this box, I hereby

authorize Delta Dental, subsidiaries,

and affiliates to charge my credit

card or initiate automatic monthly

or annual withdrawals (ACH) from

the account information that will be

provided in the next screen. This

authorization will remain in effect

until Delta Dental has received

written notification from me to the

following email address:

adzh20@r.postjobfree.com of its

termination and/or my payment

obligation has been satisfied. I

understand that I am responsible for

any fees incurred due to my

payment being rejected for

processing by my bank

Turquoise Plan-767

$24.93

Frequency

Monthly

Me :: 10/21/1974

Effective i Date :: 04/01/2023

If I am paying by ACH, I hereby authorize Delta

Dental, its subsidiaries, and affiliates to initiate monthly or annual automatic withdrawals

(ACH) based on the frequency selected above

from the account indicated. This authorization

will remain in effect until Delta Dental has

received written notification to the following

email address: adzh20@r.postjobfree.com of

its termination and/or my payment obligation

has been satisfied. I understand that I am

responsible for any fees incurred due to my

payment being rejected for processing by my

bank. If I am paying by credit card, I hereby

authorize Delta Dental, its subsidiaries, and

affiliates to charge my credit card for premiums

due. This authorization will remain in effect until Delta Dental has received written notice from

me of its termination. If the billing amount

changes, Delta Dental will provide a minimum

of 10 days' notice to the cardholder

Questions?

Need help? Call us at 800-***-****

Home

Contact Us

About Us Dentist Login

Website Privacy Policy

HIPAA Privacy Policy

Nondiscrimination and Accessibility

ACA-Compliant Dental Insurance

Language Assistance Services

© Arizona Dental Insurance Service, Inc. dba Delta Dental of Arizona

EDIT

CONTINUE

Contact this candidate