For Eligible Participants of the UFCW Local 1776 and Participating
Employers Health and Welfare Fund

You must file a Dental Enrollment Form with the Fund office to participate in the Dental Plan. You may enroll in the Dental Plan's network of participating dentists, or you may enroll with a non-participating dentist. Whichever you choose, your election will be in effect for your entire family and will remain in effect as long as you are eligible for benefits through the Fund office or until changed by you. You may change your election only once every twelve months. You must first notify the Fund office of any change. Please read the following information carefully. After you make your selection, return your completed Dental Enrollment Form to the Fund office as soon as possible. Enrollment information must be received one month prior to your visiting a participating dentist.
Your dental enrollment selection determines the way in which your claims are paid, even if services are provided by participating dental plan providers.