Comptroller of the Currency Dental Program (OCC)<br />Online Customer Service Inquiry Form>

REQUESTOR INFORMATION
Required fields are denoted by a red asterisk (*).
* Country:

* First Name:
* Last Name:
* E-mail Address:		The "Email" field is required.
* Requestor Status:	Enrolled Not Enrolled Benefits Administrator

SUBSCRIBER INFORMATION
* Subscriber First Name:
* Subscriber Last Name:
* Subscriber Date of Birth:	/ / MM/DD/YYYY
* Subscriber ID:	(9-digit number without hyphens or spaces)

NATURE OF INQUIRY

*	ARE YOU INQUIRING ON A CLAIM?	No Yes
Please provide the 13-digit Claim Number in the area provided below. The Claim Number is located on Page 2 in the upper left portion of your Explanation of Benefits. * Claim Number (13-digits)

	SUBMITTING STUDENT VERIFICATION. * Attachment required

	I AM NEWLY RETIRED AND ELIGIBLE FOR 12-MONTH WAIVER. If you weren’t able to enroll via the Beneficiary Web Enrollment (BWE) until your retirement was official, and you would like us to consider backdating your coverage effective date so you can avoid a lapse in coverage from the TDP, please notate that in the Inquiry Details area at the bottom of this form • In order to be eligible for this, you would have had to enroll the same month in which you retired.

Attachments

A maximum of two files may be attached per inquiry. Maximum file size is 15MB.
Accepted file types are doc, docx, xls, xlsx, xlsm, pdf, txt, jpg, jpeg, tif and tiff.

Security Question

Select one verification method Enter displayed characters Answer a simple question

*Response:

Comptroller of the Currency Dental Program (OCC)
Online Customer Service Inquiry Form

REQUESTOR INFORMATION

SUBSCRIBER INFORMATION

NATURE OF INQUIRY

INQUIRY DETAILS

Attachments

Security Question

Comptroller of the Currency Dental Program (OCC) Online Customer Service Inquiry Form

REQUESTOR INFORMATION

SUBSCRIBER INFORMATION

NATURE OF INQUIRY

INQUIRY DETAILS

Attachments

Security Question

Comptroller of the Currency Dental Program (OCC)
Online Customer Service Inquiry Form