Dental Enrollment / Change Form

Dental Enrollment / Change Form
*Denotes required fields for enrollment. For items with ** please select a Reason for Enrollment OR Change.
EMPLOYER INFORMATION: To Be Completed By Employer
A
Company Name: ____________________________________
*Group No.: _____________________________________________
Date Employed Full Time: _____________________________
*Effective Date of Coverage or Change _____________________
REASON FOR ENROLLMENT OR CHANGE
ENROLL
□
□
□
□
□
Open Enrollment
New Group
New Hire
□ Group Request
□ Member Request
□ Qualifying Event (Reason)
COBRA
Date
Add Dependent
**List Reason:
/
TERMINATE COVERAGE
.
/
CHANGE
□ Terminate Subscriber
□ Terminate Dependent
□ Deceased
□ Termination Reason:
□ Name
□ Address/Phone
.
.
.
Employee Status:
Active
COBRA
Salary
Hourly
.
Number of hours a week
Benefits Administrator Approval:
.
Other
Date:
DENTAL COVERAGE ELECTION
B
Dental Plan Code1
I ELECT THE FOLLOWING FOR MYSELF AND MY DEPENDENT(S):
Type of Coverage:
Employee
Employee/Spouse
.
Employee/Children.
Employee/Child
Employee/Spouse/Child(ren)
DENTAL WAIVER ( only complete if waiving coverage)
C
I understand that if I decide to apply for dental coverage for myself and any applicable dependents(s) at a later date, neither my dependent(s) nor
I will be eligible for coverage until (1) my employer’s next open enrollment period, or (2) there is a qualifying event as defined in the EOC/COI.
Waive Dental
Myself
Spouse
Dependent(s)
□ Other Insurance
Reason:
□ Other Reason (please explain)
□ Spousal Coverage
.
.
Employee Signature (only if you are waiving coverage)
D
.
Date
EMPLOYEE INFORMATION
*Last Name
*Gender
*First Name
□ Male
□ Female
*Birthdate
MI
*Social Security Number
*Address
*State
*City
Work Phone
E
*Zip Code
Home Phone
FAMILY MEMBERS TO BE COVERED OR DELETED
FULL NAME (Last, First, MI)
□ Enroll
□ Delete
□ Enroll
□ Delete
□ Enroll
□ Delete
□ Enroll
□ Delete
F OTHER DENTAL COVERAGE
if address and phone numbers of covered dependents are different from those of policyholder,
please attach that information on a separate sheet of paper.
SEX
RELATIONSHIP
BIRTHDATE
/
/
-
-
M F
/
/
-
-
M F
/
/
-
-
M F
/
/
-
-
M F
SPOUSE
WHEN coverage BEGINS, will you or any of your family members have any other dental insurance coverage?
G
SOCIAL SECURITY #
Yes
No
EMPLOYEE SIGNATURE
I represent that all information supplied in this application is true and correct. I have thoroughly reviewed, understand, and accurately responded to all
questions and information on this application. I hereby agree to the conditions of enrollment on the reverse side of this form.
.
.Employee Signature
Date
1
Underwritten by Coventry Health and Life Insurance Company 6705 Rockledge Drive, Ste 900 Bethesda, MD 20817
.
Continued on back
AR_GDSENROLL08_CHL
Approved
10/09/08
Acceptance of Coverage
Please make a copy for your records
I accept the insurance provided by my employer’s group insurance plan. I authorize deductions from my earnings for the required
contributions toward the cost of insurance. (This authorization applies only if employee contributions are required.) I understand that
by accepting insurance, I am required to remain enrolled as a covered employee and cannot make an elective change in the coverage
selected until the next open enrollment period, if there is one provided for in the Master Agreement to Provide Dental Benefits.
Fraud Statements
Attention California: For your protection, California law requires notice of the following: Any person who
knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing
any materially false or misleading information is guilty of a crime and may be subject to fines, confinement in
a state prison, and substantial civil penalties.
Attention Colorado Residents: An insurer or agent who knowingly provides false or misleading information
to defraud a claimant regarding insurance proceeds must be reported to the Insurance Division.
Attention Florida and Virginia Residents: Any person who knowingly and with intent to injure, defraud or
deceive any insurer files a statement of claim or an application containing any false, incomplete or
misleading information is guilty of a felony of the third degree.
Attention Maryland Residents: It is a crime to knowingly provide, or to knowingly assist, abet, or
conspire with another to provide false, incomplete, or misleading information to an insurance
company with intent to injure, defraud, or deceive the company or any other person. Penalties
include imprisonment, fines, and denial of insurance benefits.
Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any materially
false information or conceals, for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Attention Residents of Other States: It is a crime to provide false or misleading information to an insurer
for the purpose of defrauding the insurer or any other person. In addition, an insurer may deny insurance
benefits if false information materially related to the claim was provided by the applicant.
AR_GDSENROLL08_CHL
Approved
10/09/08