Group Employee Enrollment

Employees that are offered a dental plan administered by American Dental Professional Services (ADPS) through their employer can enroll here. If you are not sure that you are eligible to enroll, please contact an Employee Benefits Specialist at your place of employment.

You can enroll by clicking here to print an application and mail to ADPS.

You may also complete the form below and submit your application to us electronically.

* indicates required fields.

Title	Mr.MissMs.Mrs.Dr.
First Name *
Last Name *
Company
Address 1 *
Address 2
City *
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip Code *
Telephone
Fax
Email
Reason for Enrollment *	New HireEmployee EnrollmentPlan ChangeAddress/Name Change/Correction
Marital Status	SingleMarriedDivorced
Social Security Number
Gender *	MaleFemale
Birth date *
Name of Employer *
Position/Division
Date of Hire *
Work Phone
Program *	Dental Care AdvantageOrthoCare
Dependent 1 Name
Dependent 1 Social Security Number
Dependent 1 Gender	MaleFemale
Dependent 1 Birth date
Dependent 2 Name
Dependent 2 Social Security Number
Dependent 2 Gender	MaleFemale
Dependent 2 Birth date
Dependent 3 Name
Dependent 3 Social Security Number
Dependent 3 Gender	MaleFemale
Dependent 3 Birth date
Dependent 4 Name
Dependent 4 Social Security Number
Dependent 4 Gender	MaleFemale
Dependent 4 Birth date
Dependent 5 Name
Dependent 5 Social Security Number
Dependent 5 Gender	MaleFemale
Dependent 5 Birth date

By submitting this form, I apply for enrollment and agree to abide by the terms and conditions of the Group Administration Agreement, and authorize my employer to make payroll deductions, if applicable.