Online Application Form (through our secure server)
Printable Application Form
Cancellation Policy
Please mail completed application form to:
Mainline Dental Plan, Inc.
9 Furler Street
Totowa, NJ 07512
Phone: 1- 877- 880- PLAN (7526)
11am - 8pm EST
Fax: (702) 880-7531
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Single Membership:
- Single coverage is for the member only.
Member & Spouse
- Includes member and spouse or domestic partner residing in the same household.
Parent/Child:
- Parent/Child coverage includes member and 1 child under the age of 18 residing in the same household.
Family Membership:
- Family coverage includes member, spouse or domestic partner, and all children under the age of 18 residing in the same household.
Group Membership:
- Group coverage can be provided for employers with 4 or more employees.
Please call our office for a quote.
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