Form Sg Enr - Enrollment Form - 2017 Page 2
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1
2Enrollment Form
Small Group Dental Coverage
COBRA Enrollment Only
Indicate Qualifying Date
Indicate Qualifying Event
Termination
Reduction in Hours
Divorce
Widowed/Surviving Dependent
Dependent Child No longer Eligible
Other
SM
Delta Dental PPO
– Options Coverage Selection (If Applicable)
Check One
I choose the Core Plan
I choose the Plus Plan
Contact your employer for more information.
Waiver Dental Coverage
I certify that I have been advised of the features and benefits of the dental plan offered to me through my employer and after due
consideration, I have chosen:
Not to enroll my spouse in the group dental plan being offered by my employer.
Not to enroll my children in the group dental plan being offered by my employer.
Not to enroll myself and my dependents in the group dental plan being offered by my employer. I understand that by
taking this action, I waive all benefits payable thereunder for myself and/or my dependents.
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines and denial of insurance benefits (R.C.W. 48.135.080).
* Domestic partners include state-registered partnerships and/or other domestic partners if specifically covered by group.
** The minimum limiting age is through age 25 for all dependent children; coverage shall not terminate for children over the age of
25 who are both:
(1)
incapable of self-sustaining employment by reason of developmental disability or physical handicap
(2)
chiefly dependent upon the employee or member for support and maintenance
*** Documentation is required to show that such child continues to be incapable of self-sustaining employment by reason of
developmental or physical disability and that such child is chiefly dependent upon the employee or member for support and
maintenance. To download the Incapacity and Dependency Form, visit the Delta Dental of Washington website at
You may also obtain a form by calling us at 1-888-899-3734.
___________________________________________
__________________________
Signature
Date
SG ENR - 2017
Page 2
Version 02 20160708
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