Dental Plus of Oregon. You re telling me my teeth can really last a lifetime? THE POLICY PROVIDES DENTAL BENEFITS ONLY.

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1 You re telling me my teeth can really last a lifetime? Dental Plus of Oregon THE POLICY PROVIDES DENTAL BENEITS ONLY. orm No. 2121D-OR(12/15) Agreement orm No OR(7/12) This discount dental plan is provided by Willamette Dental Insurance, Inc.

2 Personal care for your individual needs Willamette Dental Insurance, Inc. is pleased to offer you Dental Plus of Oregon, a cost saving dental discount plan. This plan gives you simple access to quality dental care at a reduced fee. Routine and preventive services are provided at 25% savings. Orthodontia is available for both adults and children at a 15% reduction on usual fees. embers do not need to fill out or submit any claim forms. As a member, you simply schedule your appointments, see the dentist and pay charges at that visit. Willamette Dental Group, P.C. dentists make access to quality dental care easy, while Dental Plus of Oregon keeps that care affordable for you and your family. Dental Plus of Oregon is not insurance. Plan members must pay for all dental and ancillary services, but will receive a discount on eligible services from Willamette Dental Group providers.

3 With more than 50 Locations throughout the Pacific Northwest, we re likely to have an office in your neighborhood. Oregon Locations Washington Oregon Idaho To receive discounted dental services, services must be received from a Willamette Dental Group provider and all charges must be paid in full at the time of the visit. Visa, astercard and Discover are accepted. embership must remain continuous during the full treatment period to receive discounted services. An advance appointment is required to receive care. To schedule your dental appointments, call our Appointment Center at DENTAL ( ), Option 1. When you speak to a Willamette Dental Group representative or arrive at the dental office for your appointment, simply identify yourself as a Dental Plus of Oregon member. You will then receive discounts on your quality dental care. ost dental offices are open onday through riday, 7 A to 6 P, and occasional Saturdays. Albany Beaverton Beaverton Specialty Bend Corvallis Eastport Eugene Gateway Specialty Grants Pass Gresham Hillsboro Lincoln City edford ilwaukie Portland Westside Roseburg Salem Lancaster Salem Liberty S.E. Stark Stark Specialty Springfield Tigard Tillamook Tualatin Weidler

4 Discount Summary Services must be received from a Willamette Dental Group provider to receive discounted services. Please check with your Willamette Dental Group, P.C. provider for charges on specific treatment. You will receive a 25% discount on Willamette Dental Group general dentist services, including: General exams Cleanings illings) Crowns You will receive a 15% discount on Willamette Dental Group specialist or denturist services, including: Orthodontia Oral surgery Pediatric dentistry Periodontics (gum & bone problems) Endodontics (root canals) Dentures You will receive a 15% discount on implant services. or Appointments, please call: DENTAL ( ) or Customer Service, please call: Willamette Dental Insurance, Inc NE Campus Way, Hillsboro, OR Annual embership ees embership fees may be paid by credit card, check or money order. Single embership $89.00 Double embership $ amily embership $ How To Enroll To enroll in Dental Plus of Oregon, simply complete the application form and submit it along with payment of membership fee. The application and membership fee payment must be received by the 25th of the month preceding the period for which membership is to be effective. You must be at least 18 years of age and a resident of Oregon. Eligible family members include your legal spouse or domestic partner and your unmarried dependent children through age 18 and through age 23 if the child is a registered full-time student at an accredited educational institution. You may not be enrolled with Willamette Dental insurance coverage. If you would like additional information please contact us at or visit us on the web at:

5 Willamette Dental - Dental Plus of Oregon Application orm Willamette Dental Insurance, Inc NE Campus Way, Hillsboro, Oregon Please print or type. Shaded areas are for producer or office use only. Account Number: Effective Date: 1 I m filling out this application because I am... a new applicant applying for: (select box below) Single membership Double embership amily embership 2 y information is... Self (Last, irst, iddle Initial) Gender ailing Address City/State/Zip Home Telephone Number Address Date of Birth Requested Effective Date 3 y premium payment will be paid by... Personal Check oney Order Credit Card (Visa, C, Discover) Credit Card Number: Expiration Date: CDC (3 digit security code): Signature: Date: 4 I want to enroll my... Legal Spouse or Domestic Partner (Last, irst, iddle Initial) Date of Birth Gender Dependent Child (Last, irst, iddle Initial) Date of Birth Gender Husband/Wife Domestic Partner Dependent Child (Last, irst, iddle Initial) Date of Birth Gender Dependent Child (Last, irst, iddle Initial) Date of Birth Gender Pay Commissions To: Producer Agency Producer or Agency Name: Producer or Agency Address: Producer or Agency Phone Number: orm No. 2121C-OR(7/12) Please continue application on back...

6 Agreement I hereby apply for membership in the discount dental plan, Dental Plus of Oregon, offered through Willamette Dental Insurance, Inc. for myself and all listed family members. I acknowledge that Willamette Dental Group reserves the right to change membership fees and provisions of the embership Agreement. I understand that payment of membership fees shall be deemed acceptance of the terms of embership Agreement. I agree to advise Willamette Dental Group of any change in status within 30 days from the date of change. To the best of my knowledge, the information I have provided in this application form is true and complete. If I choose to sign this application by typing my name below, I acknowledge and agree that my typewritten signature has the same legal effect as my written signature on this application. Applicant s signature: Date: ail this completed application and your membership payment to: Willamette Dental Insurance, Inc. Dental Plus of Oregon 6950 NE Campus Way Hillsboro, OR You can also or fax your completed application to: wd.insurancelist@willamettedental.com or ake checks payable to: Willamette Dental Insurance, Inc. Summary of Exclusions The following services are not eligible for a discount through this plan: Services provided by a provider other than a Willamette Dental Group provider. Services received before the effective date, prior to cancellation for a full refund, or after the termination of membership. General anesthesia, including conscious, intravenous and moderate sedation Hospitalization charges Dental treatment not performed in a Willamette Dental Group office. Cosmetic dentistry. Dental treatment which your Willamette Dental Group provider determines to be unnecessary. Charges by any person other than a licensed dentist, licensed denturist, or licensed hygienist. This plan does not coordinate benefits. Please refer to your agreement for a complete description of terms, conditions and exclusions.