Form E62 - Membership Maintenance Form - Delta Dental Of Nebraska (Page 2 of 2) in pdf

Instructions for Completion of Membership Maintenance Form

Important Notes:

• Type or print clearly with a pen.

• All dates should be written in MM/DD/YYYY format.

• When reporting effective dates, use contractual start and stop guidelines as defined in your contract (i.e., 1

month, end of month, or actual dates).

• Before submitting, review it to ensure you have provided all necessary information.

• If information is missing or illegible, this form will be returned to you and may delay your enrollment.

• Enrollment requests are generally completed within five business days of receipt by Delta Dental of Nebraska.

Part A: Employee Information - Complete all sections.

Part B: Change Request

• Name Change – Provide name as previously reported and new name.

• Terminate Employee and All Dependents – Only use this section if the employee and all dependent

coverage is being terminated.

• Change Employee Group/Subgroup – Move employee from one group/subgroup to another for benefit,

report or COBRA purposes.

• Coverage Type Change – Complete this section to change Coverage Type and to add or drop dependent

coverage. Provide detailed information for each dependent being added or dropped in Part C.

Part C: Dependent Information

• List dependents to be added or dropped if requested in Part B.

• Complete all sections for each dependent.

• If more than four dependents are being reported, attach a list of additional dependent information in same

format.

Part D: Employee Signature

• Please read and sign form as verification of your change request.

• Return completed form to your benefit administrator.

Part E: COBRA – Complete this section only if an individual has selected continuation of coverage under

COBRA.

• Select a Coverage Type, the appropriate Qualifying Event Number, Date of Qualifying Event and Effective

Date of Coverage.

• If employee is not enrolling for COBRA, provide Social Security Number of individual who is being enrolled.

• If group has a separate COBRA subgroup, it must be provided in Part B.

Part F: Group Information – Completed By Employer

• Group Name – Provide group name as listed in your contract.

• Group and Subgroup Number – Provide applicable numbers for individual employee.

• Group Representative – Sign, date, and provide your phone number.

Send Completed Forms To:

Delta Dental of Nebraska

Attn: Enrollment Department

PO Box 330

Minneapolis MN 55440-0330

Form E62 - Membership Maintenance Form - Delta Dental Of Nebraska Page 2