Dental Benefits Enrollment/coverage Status Form - Delta Dental Nm

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Dental Benefits Enrollment/Coverage Status Form
PART A – Employee/Employer Information
Employee name (last, first, middle initial)
Gender
Married?
Social Security Number
Date of Birth
 
M
F
Y
N
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ /__ __ __ __
Name of Employer
Employee’s Work Site Location/Branch
Date of Hire
__ __ /__ __ /__ __ __ __
Employee Position/Title
Do you have other dental benefits?
Yes
No
Name of other plan, if applicable:
Home mailing address (including City, State, ZIP Code)
Check here if new address
PART B – Enrollment or Other Action Required
Waive Coverage—Please
Cancel Employee Coverage (also cancels dependent coverage,
Enroll in Dental Plan
complete and sign Part F
if applicable)
Enrollee Category
Active Employee
Add Dependents (list new dependents to be covered in Part C)
Retiree
Cancel Dependent Coverage
COBRA
On all dependents currently enrolled
Network Selection, if applicable to your plan
On dependent(s) listed here:
Coverage Effective/Change/Coverage Termination Date
. Reason for Action (at least one box must be checked; check all that apply):
Birth
Adoption
Date:
New Hire
Death
Date:
Termination of Employment Date:
Change of Address
Initial or Open Enrollment
Loss of Eligibility due to:
Retirement
Age
Marriage
Date:
Other
Other
Divorce
Date:
PART C – Dependent Information – For Dependents to be Enrolled (
For additional dependents, use a separate sheet and attach.)
Dependent to be enrolled (last, first, middle initial)
Gender
Social Security Number
Date of Birth
M
F
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ /__ __ __ __
Yes
No
Relationship
Does he/she have other dental benefits?
Name of other plan, if applicable:
Dependent to be enrolled (last, first, middle initial)
Gender
Social Security Number
Date of Birth
M
F
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ /__ __ __ __
Relationship
Yes
No
Does he/she have other dental benefits?
Name of other plan, if applicable:
Dependent to be enrolled (last, first, middle initial)
Gender
Social Security Number
Date of Birth
M
F
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ /__ __ __ __
Relationship
Yes
No
Does he/she have other dental benefits?
Name of other plan, if applicable:
Dependent to be enrolled (last, first, middle initial)
Gender
Social Security Number
Date of Birth
M
F
__ __ __ - __ __ - __ __ __ __
__ __ /__ __ /__ __ __ __
Relationship
Yes
No
Does he/she have other dental benefits?
Name of other plan, if applicable:
PART D – Signature for Enrollment and Change of Status
If enrolled, I agree to make the required contribution as stated in the group contract and to repay promptly any benefit payments to which I or my dependents were
not entitled. I certify that the information contained in this form is true and correct to the best of my knowledge. Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to civil fines and criminal penalties.
Signature
Date
PART E – For Delta Dental Use Only
Group Number
Effective Date of Enrollment and/or Change
Termination Date
Sign this section only if you are waiving Delta Dental coverage
PART F – Waiver of Coverage —
I hereby decline coverage because:
I have other dental coverage. If other coverage, who is you current carrier?
Other Reason for Waiver:
I understand that future enrollment of myself or my dependent(s) is subject to the eligibility requirements of my employer’s dental plan.
Please check with your group administrator to see if your plan allows for a future open enrollment period.
Signature
Date
Delta Dental of New Mexico Enrollment Form (Form 75)— Rev. 8/2007

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