Application for Dentists

To apply for this important coverage; complete, print, sign and either mail, scan and e-mail or fax the application to us. Mail it to Harold Diers & Company in Omaha at 11635 Arbor St., Suite 230, zip is 68144. Fax toll free to 888-314-5009. Email it to dentist@hdiers.com. Click below to open the form.