Health Insurance for the Quad Cities

(866) 440-1885

Dental Insurance Application

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Gender *

Tobacco User?

Date of birth *

Please Select your Marital Status *

Please enter your Spouse's First Name *

Please enter your Spouse's Last Name *

Please select your Spouse's Gender *

Please select your Spouse's Date of Birth *

Is Spouse a Tobacco User?

Will Your Spouse Be Included on the Dental Policy? *

Do you have any children? *

Number of Children *

Enter child's information

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this child as well? *

Enter child's information

First Name *

Last Name

Date of Birth

Do you wish to Enroll this child as well? *

Enter child's information

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this child as well? *

Enter child's information

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this child as well? *

Enter child's information

First Name *

Last Name *

Date of Birth *

Do you wish to enroll this child as well? *

Our dental insurance application is quick and easy. It takes only 3 minutes to fill out. Once complete, we will email your the best 3 options that fit within your budget.

Our dental plans include . . .

All dental plans are on a Nationwide PPO network.
Accepted by all dentists everywhere.
No waiting periods for major services.
Some plans include implant coverage.
Affordable rates.
Up to $3,000 per year covered.
Same day approval - use your insurance right away.
Covered bi-annual cleanings.

© 2025 Mohring Insurance Services LLC | Davenport, IA. | (866) 440-1885

Privacy Policy | Terms & Conditions | HIPAA Privacy Statement

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day / 7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

MohringInsurance.com is the web- and phone-based insurance portal utilized by Mohring Insurance Services, LLC. Beneficiaries may be connected by licensed insurance agents of Mohring Insurance Services LLC who are licensed to transact business as insurance agents in 39 states.

Not all licensed insurance agents with Mohring Insurance Services LLC are licensed to sell all products. Service and product availability varies by state. Agents of Mohring Insurance Services LLC work with Medicare enrollees to explain Medicare Advantage, Medicare Supplement Insurance, and Prescription Drug Plan options. Agents of Mohring Insurance Services LLC are licensed and certified representatives of Medicare Advantage HMO, PPO, and PPFS organizations and stand-alone prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal.

Licensed insurance agents may be compensated based on a consumer's enrollment in a health plan. No obligation to enroll. Licensed agents cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled.

Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

Medicare has neither reviewed nor endorsed this information.

Licensed insurance agents required to comply with all applicable federal laws, including the standards established under 45 C.F.R. § 155.220(c) and (d) and standards established under 45 C.F.R. § 155.260 to protect the privacy and security of personally identifiable information.

The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. To learn more about a plan’s nondiscrimination policy, please contact the plan.

For a complete list of available plans please contact 1-800-MEDICARE, TTY 711, 24 hours a day/7 days a week or consult www.medicare.gov.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.

Every year, Medicare evaluates plans based on a 5-star rating system.

You are not required to provide any health related information unless it will be used to determine enrollment eligibility.

MohringInsurance.com is not connected with or endorsed by the United States government or the federal Medicare program.

Rates are reviewed periodically and are subject to change in your state.

Cost Estimates are based on the information entered on Get Started, using data about past experiences by beneficiaries with similar attributes and the premiums and benefits provided by the plan. Actual costs may vary. Monthly medical costs are represented by annual figures divided evenly per month.

Licensed sales agents/producers may be compensated based on your enrollment in a health plan.

Medicare Supplement Plans are not connected with or endorsed by the U.S. Government or the federal Medicare program.

Preference Score based on the answers provided within "Other Preferences" page in Guided Help.

For plans that provide drug coverage, the formulary may change during the year.

Health Insurance for the Quad Cities

Dental Insurance Application

Our dental plans include . . .

© 2025 Mohring Insurance Services LLC | Davenport, IA. | (866) 440-1885

Privacy Policy | Terms & Conditions | HIPAA Privacy Statement

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Rates are reviewed periodically and are subject to change in your state.

Medicare beneficiaries may also enroll in Medicare plans through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.