Complete Your Enrollment Request

The plan you selected isn’t currently available for direct online enrollment at this time. However, you can begin your enrollment request by following the steps below. 

Some insurance carriers require a licensed agent to guide the process due to certain plan structures, eligibility checks, or enrollment regulations.

To help complete your application correctly and efficiently, please fill out the brief form below. A licensed affiliate agent advisor will follow up to provide plan details, confirm your eligibility, and assist with any required next steps.

While some plans on this platform offer instant self-enrollment, others—like this one—require agent support to ensure compliance, accuracy, and a personalized experience. 

This step helps you:

• Get clear answers about benefits and coverage
   
• Avoid errors that may delay your application
   
• Complete enrollment securely and in line with carrier requirements

• Submitting this form does not guarantee coverage. Final eligibility and approval are determined by the insurance carrier.
   
• The advisor contacting you is an independent licensed affiliate, not an employee of US Dental Adviser or TAC Services.
   
• Your information is used only for this inquiry and is never sold or shared with unrelated third parties.