Fillable Delta Dental Enrollment Form printable pdf download

ENROLLMENT/CHANGE OF STATUS/WAIVER FORM

PLEASE KEEP A COPY FOR YOUR FILES.

Please note that completing this form does not guarantee coverage.

ALL GROUPS MUST COMPLETE THIS SECTION

Note: Incomplete forms will be returned.

I I

Delta Dental Group Number______________________ Sublocation Number_______________________

Hourly

Salaried

I I

Effective Date_______________ Date of Hire________________ OR Date of Rehire_______________

Union

Non-Union

I I

Name of Employer______________________________ Location/Department______________________

Other_________________

Group Contact____________________________ Phone_________________________________ Email_________________________________

ALL ENROLLEES MUST COMPLETE THE FOLLOWING SECTIONS

Please check one of the options below.

I I

Yes, I want to enroll in the dental plan offered by Delta Dental of Illinois. (Please select a network below.)

I I

Delta Dental PPO/Delta Dental Premier

DeltaCare DHMO (If selecting DeltaCare DHMO, please complete the DeltaCare DHMO Facility Election section below.)

I I

No, I do not want to enroll in the dental plan offered by Delta Dental of Illinois.

(If you are declining, please write your name below and sign at the bottom of this form)

Social Security Number_______________________________ Employee’s Name_____________________________________________________

First Name

Last Name

Mailing Address___________________________________________________________________________________________________________

Street

City

State

Zip

I I

Phone Number_______________________ Marital Status:

Other

Date of Birth _____/_____/_____

Male

Female

REASON FOR SUBMITTING THIS FORM

I I

Reinstatement Due to Qualifying Event?

Yes

If yes, please describe_______________________________________________________

I I

Open Enrollment

COBRA

If COBRA, End Date _____/_____/_____

I I

New Employee

Reinstatement

Change

If this is for a change, what is the reason?__________________________________________

I I

Address Change

Termination (Reason:________________________________________________)

Termination Date_____/_____/_____

I I

Add Dependent Coverage (List Dependents below)*

(Reason:____________________________________)

Date of Event_____/_____/_____

I I

Drop Dependent Coverage (List Dependents below)* (Reason:____________________________________)

Date of Event_____/_____/_____

*If you are adding or dropping a dependent due to a qualifying event, please describe:___________________________________________________

I I

Name Change (Former Name:_________________________________________)

DELTACARE DHMO FACILITY ELECTION

If DeltaCare DHMO enrollment: Dentist Name:__________________________ Address:_________________________ Facility Code:_______

I I

Dentist Change (DeltaCare DHMO only): Dentist Name:_______________________ Address:____________________ Facility Code:_______

COVERAGE DESIRED

I I

Employee Only

Employee & Spouse

Employee & One Child

Employee & Children

Entire Family

I I

Effective Date:_____/_____/_____ Does spouse have a dental plan?

Yes

Are dependents covered by spouse’s plan?

Yes

Spouse’s Employer:___________________________________________

Spouse’s Carrier:___________________________________________

PLEASE LIST ALL ELIGIBLE DEPENDENTS TO BE COVERED

ADD DELETE FIRST NAME

LAST NAME (if different)

BIRTH DATE (Month/Day/Year) SEX (M or F)

1. Spouse:

2. Child:

I agree to continue membership in this program until the next open enrollment period and authorize payroll deduction where applicable.

Signature of applicant:________________________________________________________________________ Date:_________________________

Mail to: Eligibility Department • P.O. Box 3384 • Lisle, IL 60532 • Fax (630) 964-2997 • Email

Delta Dental of Illinois

DEL7014

516

Delta Dental Enrollment Form

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