Form E62 - Membership Maintenance Form - Delta Dental Of Nebraska printable pdf download

Delta Dental of Nebraska

Membership Maintenance Form

PART A - EMPLOYEE INFORMATION

Last

First

Middle Initial

Social Security Number

Employee’s

Name:

Male

Female

Single

Married

Widowed

Divorced

Legally Separated

Date of Birth (Month-Day-Year)

Gender:

Marital

Status:

Employee’s

Address

Home Phone Number

Work Phone Number

Address:

(

)

(

)

Check If

City

State

Zip Code

New Address

PART B – CHANGE REQUEST - Check All Categories That Apply – Provide Information Requested By Category

Name Change

Former Name:________________________________________________________________________________________

New Name: _________________________________________________________________________________________

Change Employee Group/Subgroup (move individual to

Terminate Employee and All Dependent Coverage

different subgroup, including COBRA subgroup)

From: ____________________ To: ____________________

Date of Termination: __________/__________/__________

Date Coverage Ends: __________/__________/__________

Effective Date of Change: __________/_________/_________

Select New Coverage Type – Complete Part C if Adding or Dropping Dependents

Qualifying Event Code: A – Adoption B – Birth

D – Divorce/Legal Separation E – Death

L – Loss of Coverage M – Marriage

S – Dependent No Longer Eligible

Qualifying

Change Request Category

Date of

Effective Date of Change

Event Code

Qualifying Event

(Complete Qualifying Event Code for Each Request)

Employee Only

Employee & Spouse

Employee & Dependent Child(ren)

Family

PART C – DEPENDENT INFORMATION – Adding or Dropping Dependents May Require a Coverage Type Change in Part B

Relationship

First Name, Middle Initial, Last Name

Date of Birth

Over Age 19 and

(Include Last Name Only if Different From Employee’s)

Gender

Add

Drop

To Employee

Month/Day/Year

Full-Time Student

Spouse

Child

Yes

Child

Yes

Child

Yes

PART D - EMPLOYEE SIGNATURE

I choose to make changes as indicated on this form and authorize payroll deduction, if applicable. If Part E is completed, I have elected to continue

coverage under this plan due to the qualifying event indicated above and I understand that in order to retain my coverage continuation, I must meet the

required payment obligations and/or other conditions as may be required.

Employee Signature:

Date:

PART E – COBRA – Employee Note: Complete Only if enrolling for COBRA benefits Employer Note – May require subgroup change

Qualifying Event Number:

3 Employee Total Disability

5 Employee Eligible For Medicare

1 Employee Termination or Reduction of Work Hours

4 Divorce or Legal Separation

6 Dependent No Longer Eligible

2 Employee Death

Event Number

Coverage Continuation Applies To:

Date of Qualifying Event

Social Security Number

Employee & All Dependents Currently Enrolled

Employee Only

Spouse Only

Dependent(s) Only – List Names in Part C

Employee & Spouse

Employee & Dependent Child(ren)

–List Names in Part C

PART F – GROUP INFORMATION - THIS PART TO BE COMPLETED BY EMPLOYER

---

Group Name:

Group & Subgroup Numbers:

(

)

Group Representative’s Signature:

Date:

Phone Number:

Send Original Copy to Delta Dental Retain Copy For Your Records

E62 08/31/06

Form E62 - Membership Maintenance Form - Delta Dental Of Nebraska

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