Dental/Vision Insurance

Dental/Vision Insurance

Please answer the questions below so that we can send the relevant Dental/Vision form(s) to the email address you provide on this form. Note that there is no separate vision form to complete.
Please confirm your benefit eligibility on the benefits webpage before completing this form.

Also be sure to review the plan details on the website prior to enrolling.

If you are a new Teamsters employee (with the exception of Public Works Supervisors), you will receive an enrollment packet in the mail and shouldn't use this form. If you have any questions, please contact Teamsters Dental at 617-241-9220.
First Name
Last Name
Email
Please use your City email address if you have one. example@example.com
Department
Employee Status
For a list of qualifying events click here.
Do you have a qualifying event?
Qualifying Event File Upload

Please upload your qualifying event documentation.
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Attachment
What would you like to do with your dental/vision benefit?
What would you like to do with your dental/vision benefit?
What type of dependent(s) would you like to add?
How many of your child(ren) are between the ages of 19-25 or are a disabled dependent?
Disabled and adult dependents may be covered long term, hence there is a distinct form for covering these dependents which will be sent to you.
Birth Certificate(s) File Upload

Please upload a birth certificate or documentation of legal guardianship for each child you wish to add as a dependent on your dental/vision plan.
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Marriage Certificate File Upload

Please upload your marriage certificate.
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Next Steps

After you click the Submit button below, we will send the dental/vision form(s) to the email address you provided on this form. It will come from "City of Cambridge Benefits Team via Adobe Acrobat Sign".

Once you complete and sign the document(s) you were sent, the form(s) will be sent to Human Resources for eligibility review and processing. You will be given an option to download your completed form(s).

If you don't see the form(s) in your inbox within 10 minutes of submitting this form, please check your spam/junk folders. If you still do not see the form(s), please contact the Benefits office at benefits@cambridgema.gov or call 617-349-1770.