Form 3400 - Dental Enrollment
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1Delta Dental Insurance Company
For Employer Use Only
Effective Date
Group No.
ENROLLMENT/CHANGE FORM
/
/
Full Time Hire Date
Sublocation
/
/
Check One
(**Enrollees can change plans only during open enrollment.)
Primary Enrollee Information
VERY IMPORTANT - PLEASE PRINT LEGIBLY (Please leave one blank box between each word)
q
q
(Last, First)
q
(Street Address)
q
(City)
(State)
(Zip)
(Pay period - if applicable)
q
(Month)
(Day)
(Year)
q
Terminate Employee Coverage
q
Spouse Employment Change
(
)
q
q
q
q
q
Marital Change
q
q
q
q
q
Other _________________________
Indicate qualifying date:
Dependent Information
(VERY IMPORTANT - PLEASE PRINT LEGIBILY. To add additional dependents, please attach a separate sheet.)
(Month)
(Day)
(Year)
Add Delete
Male Female
COBRA Enrollment Only
q
q
q
q
(Month)
(Day)
(Year)
Please indicate qualifying event:
q
q
q
q
q
Termination
(Month)
(Day)
(Year)
q
q
q
q
q
Reduction in Hours
(Month)
(Day)
(Year)
q
q
q
q
q
Divorce
(Month)
(Day)
(Year)
q
q
q
q
q
Widowed/Surviving Dependent
(Month)
(Day)
(Year)
q
q
q
q
q
Dependent Child No Longer Eligible
(Month)
(Day)
(Year)
q
q
q
q
Indicate qualifying date:
(Month)
(Day)
(Year)
q
q
q
q
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
q
I authorize any payroll deduction that may be required towards the cost of this coverage. I certify that the information in this form is true and correct to the best of my ability. I understand
that my election cannot be changed during the year unless I experience a change in family status and the election change is consistent with the family status change.
q
I decline coverage at this time.
Notice: 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.
Original
Form 3400 (Rev. 7-01)
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