Form Sg Enr - Enrollment Form - 2017
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1
2Enrollment Form
Small Group Dental Coverage
PO Box 75688
Seattle WA 98175-0688
(800) 554-1907
New
Open Enrollment
COBRA
Reinstate
Change
|
_________________________
Description of Changes:
Subscriber Information
(please complete all fields)
Employer or Group Name
Group Number Subgroup
Hire Date
Effective Date
First Name
Middle Initial
Last Name
Social Security Number
Birthdate
Gender
Address
City
State
ZIP Code
Email
Phone Number
Dependent Information
Please list all dependents to be covered:
Middle
Does this person have
First Name
Initial
Last Name
Birthdate
Gender
Add / Remove
other Dental Coverage?
Spouse or Domestic Partner*
Add
Remove
Yes No
Dependent Child**
Add
Remove
Yes No
Dependent Child**
Add
Remove
Yes No
Dependent Child**
Add
Remove
Yes No
Dependent Child**
Add
Remove
Yes No
Yes*** No
Are any of your dependents being covered past the limiting age due to incapacitation?
Coordination of Benefits
Please complete this section if you or your dependents have any other dental coverage.
Please check all that coverage applies to:
Self All Dependents with other coverage Dependent(s) (Specify)
___________________
Employer Group Number and Name
Effective Date
Name and Address of Insurance Carrier
First Name
Middle Initial
Last Name
Social Security Number
Birthdate
Gender
For additional COB information please submit on an additional form or call (800) 554-1907.
SG ENR - 2017
Page 1
Version 02 20160708
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Parent category: Business