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Claim for each such violation. Signature Date Broker Information (if applicable) Broker Name F-2452 SSN/Tax ID# -OVERPrint 12/16 Rev. 01/15 Plan Underwritten by: Plan Administered by: DELIVERY SYSTEMS, INC. Dentcare Delivery Systems, Inc. 333 Earle Ovington Blvd., Suite 300 Uniondale, NY 11553-3608 www.healthplex.com P 800-468-0466 F 516-745-0079 New York CapDent Individual Dental Plan Enrollment Form Terms & Conditions Benefits I understand that the In-Network benefits insured by De.

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