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NJ Dental Insurance Quotes Logo Membership enrollment form

                                 It is very easy to enroll

                                       ●Select a plan
                                          ●Enter your information
                                                                                        ●Select a dentist
                                                                                        ●If applicable, enter your dependents
                                                                                       ●Make your payment

***EVERY PLAN IS BACKED BY OUR MONEY BACK GUARANTEE***

Choose a plan below

Capdent NJ Plan- Single $153.60/a year Family $381.60/a year

Applicant information
first name*	middle initial	last name*
social security #* date of birth* -- // street address* street address 2 city* state zip code*
daytime phone #* --	evening phone # --	email address*

Choose a dentist
Please note: it is not necessary to choose a dentist at this time. However if you would like to choose a dentist now please click here. Please search under option 1 and fill in the name of dentist and the ID on the right.	dentist name	dentist id

Dependent information
first name, last name	gender	birthday mm/dd/yyyy	relationship	student yes or no
		//
		//
		//
		//
		//
		//

Your total payment is: the annual cost for the plan you chose, plus a one time processing fee of $39.99. Please enter payment information below. Thank you. We greatly appreciate having you as our valued client! ***This plan is backed by our money back guarantee.

Payment information

Please enter payment information below.

     name as it appears on card*          billing zip code*

          account #*                        expiration date*           cvc #*
         /
      credit card type*

Where can I find the cvc # and what is it?

Payment authorization ( this is the last step)

I hereby apply for the dental insurance plan that I selected in my web application. I have read and understand when my plan will take effect. I have also read and understand the cancellation policy.

I hereby authorize Healthplex and/or The Oved Agency to charge my credit card. I also authorize The Oved Agency to charge my credit card account the $39.99 processing fee.

By clicking on “submit,” you certify that you have read and understand the above statements. Additionally, clicking on “submit” represents your signature in lieu of your physical signature for application confirmation and acceptance purposes and that you agree to pay the charges as per the credit card contract.

applicant full name