Dentalselect Employee Change Form

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Employee Change Form
DentalSelect
Toll Free: 800-999-9789
Toll Free Fax: 888-998-8704
.com
Must be completed in FULL – PLEASE PRINT
– Change Form is not valid without signature(s)
Employer’s Full Name
Employer’s Address
Group Number
Subgroup/Dept. #
Effective Date
(MM/DD/YY)
Subscribers Name
SSN/Member #
Personal Information Selection
- Change of name and/or Address.
Old Employee Name
New Employee Name
New Address
City
State
Zip Code
Phone #
Coverage Selection
- Confirm available options with your employer. Check all that apply. Please note that changes may result in premium adjustments.
Requested Dental Plan
Requested Vision Plan
Discount - Silver
Co-Insurance Indemnity - Platinum
High
Low
Vis 1
Vis 2
Vis 3
Co-Pay - Gold
Co-Insurance PPO/MAC - Platinum
Vis 4
Vis 5
Vis 6
Dual Options - If applicable, select High or Low to
indicate plan type, otherwise leave blank.
Co-Pay - Platinum
Co-Insurance Passive PPO - Platinum
Vis 7
Vis 8
Vis 9
Co-Insurance PPO* - Gold
ACA EHB Child Only
Vis 10
Vis 11
* Where permitted by law
Co-Insurance PPO* - Platinum
Other _________________
Other ____________
Reason/Status
- (Required for all requested changes - Notice must be given to Dental Select within 30 days)
(Cancel as indicated)
Rehire
Other - Mark One
Termination
Death
Marriage
Date of Layoff:____/____/_____
Rehire Date:____/____/_____
Entire Policy
Birth
Address Change
Divorce
Dependent (as indicated below)
Loss/Gain of Coverage - Employee and/or Dependent
Adoption
Name Change
Leave of Absence
Dental
Date of Change:____/____/_____
Effective Date:____/____/_____
Insured Vision
Date of Change:____/____/_____ Effective Date:____/____/_____
AD&D
Employee Part to Full Time
COBRA - Mark One
COBRA
Date of Change:____/____/_____
Effective Date:____/____/_____
18 months - Termination
36 months - Divorce. Loss of Subscriber, Etc.
Cancel Date:____/____/_____
Effective Date:____/____/_____
Cancel Date:____/____/_____
Individuals Covered
- List individuals for whom you are changing and/or terminating.
Spouse Name -
Gender
SSN
Date of Birth -
(Last, First, MI)
(MM/DD/YYYY)
Dental
COBRA
Add
Male
Terminate
Vision
Female
Change
AD&D
Dependent Name -
Gender
SSN
Date of Birth -
(Last, First, MI)
(MM/DD/YYYY)
Add
Dental
COBRA
Male
Terminate
Vision
Female
Change
AD&D
Dependent Name -
Gender
SSN
Date of Birth -
(Last, First, MI)
(MM/DD/YYYY)
Add
Dental
COBRA
Male
Terminate
Vision
Female
Change
AD&D
Dependent Name -
Gender
SSN
Date of Birth -
(Last, First, MI)
(MM/DD/YYYY)
Add
Dental
COBRA
Male
Terminate
Vision
Female
Change
AD&D
Authorization of Change
- (Required for all requested changes - Notice must be given to Dental Select within 30 days)
Employer Signature (Required)
Title
Date Signed (MM/DD/YYYY)
Subscribers Signature
Date Signed (MM/DD/YYYY)
WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT
AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
In the event there is a discrepancy regarding any information contained in this form, documentation will be required.
Mail: Dental Select (Attn: Eligibility) 5373 S. Green Street, 4th Floor, Salt Lake City, UT 84123 Fax: (801) 290-5101 Toll Free Fax: (888) 998-8704
ALL 2014 ECF12/13

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