Enrollment Instructions for IBO CIGNA Dental DHMO (K1-09) Enrollment Form
Eligibility for Enrollment
You are eligible to enroll in our CIGNA Dental Care DMHO Plan if you are an active IBO and a member of the Independent Business Owners Benefits Association (IBOBA) or spouse and/or dependent child, a U.S. citizen living in the United States and hold a social security number, you may enroll.
Once you are enrolled under this CIGNA group plan, should your coverage terminate for any reason, you (and your eligible spouse and/or dependent children) will have to satisfy a 12-month waiting period to re-enroll.
Listed below are easy to follow step-by-step instructions to complete and submit the IBO CIGNA Dental DHMO Enrollment Form.
- Read the details of the CIGNA Dental DHMO enrollment coverage, limitations, and exclusions thoroughly located under the “Dental DHMO Plan” tab on this website.
- Please complete the enrollment form titled "Cigna Dental DHMO Enrollment Form" by typing (or print and handwrite in ink) the following information:
- IBO Number is required, IBO Level is optional
- General Information is required except providing an email address is optional
- Complete the section "all persons to be covered" which includes a social security number for all those you are enrolling. If someone does not have a social security number, please contact our office for further instructions. The Dental Office Selection is a number assigned to your dentist and is required; if you do not have your dentist's Dental Office Selection number, contact our office for further instructions.
- Fill in your monthly premium and the date you are completing the form
- If you are typing the information directly onto the form, make sure to print the form and then sign the form. Digital signatures are not acceptable, you must sign the form
- Mail the completed enrollment form and your initial premium to:
USI Affinity
14 Cliffwood Ave., Suite 310
Matawan, NJ 07747
Your initial premium is required when applying for dental coverage. Please make your payment payable to “USI Affinity” and attach payment with your completed enrollment form. You may also pay your premium with your Visa, MasterCard, or Discover credit card or debit card. Simply print this credit card payment form, complete the information, and return the signed and completed form with your application.
Please note: An incomplete enrollment without your initial payment will be returned to you. This will delay your enrollment.
Your coverage will be effective on the first day of the month following approval of your enrollment form providing initial down payment has been paid. Do not cancel any other coverage until you have been notified, in writing, of your approval and you have received your certificate of coverage from USI Affinity.
If you have any questions or need assistance in completing your enrollment, please contact one of our professionals at 1-800-254-2327, or email us with your questions.
Download a copy of the CIGNA Dental DHMO Enrollment Form.