For information or dental quotes please contact:

Joanna S. Jungen
Sales Operations Manager
1812 University Blvd.
Suite 1
PO Box 1250
Tuscaloosa, AL 35401

205.343.1246 phone
205.409.2532 fax
866.839.5308
jjungen@southlandbenefit.com

Group Enrollment Forms
1. New Group Checklist/Transmittal Form
2. Group Dental Master Application
3. Benefit Enrollment/Change Form
4. Nominate Your Dental Provider Form
5. Group VisionChoice Master Application
6. Nominate Your Vision Provider Form
7. Dental Quote Request Form

Dental Broker Appointment Forms
1. Dental Broker Appointment Instructions
2. Dental Broker Application
3. Brokerage Agreement
4. Investigative Report Release
5. W-9 Form