A six-digit numeric code that can be found on any recent marketing materials you may have received from Colibri Health in the mail or viewed online The date that your policy is effective. Policies can be effective on either the 1st or 15th of the month and is within 60 days of the application signature date. Coverage start date may change based on the qualifying event. Birth date OR Age as of Coverage Start Date Tobacco usage includes use of cigarettes, cigars, pipe tobacco, chewing tobacco product containing the leaves of the tobacco plant for smoking or ingestion.

A tobacco user is a person who has used tobacco an average of 4 or more times per week during the past 6 months, not counting use for religious or ceremonial reasons.
First Name is required for the Primary subscriber only Last Name is required for the Primary subscriber only

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For Individual and Family Dental Insurance

Please enter all required information. All fields marked with an (*) must be completed. All fields marked with an (*) must be completed.

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* Coverage Start Date Currently Insured? Yes    No
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Please enter the information below for the individual(s) you wish to cover.
Individual * First Name  * Last Name  * Date of Birth  * Gender * Tobacco User   
Primary
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“$1 per day coverage” applies to BluePreferred Dental Plan 1i for an individual adult monthly premium. Additional cost-share applies for most covered services.