Enrollment Form printable pdf download

ENROLLMENT FORM

Personal Information

Please fill out this form entirely. Incomplete forms will delay your application.

NEARI Membership Number

Social Security Number

Date of Birth

(MM/DD/YYYY)

First Name

Last Name

Street Address / P.O. Box Number

City

State

Zip Code

Email Address

Telephone Number

Coverage Type & Premium Rates Please select a coverage type (Individual, Two-Person or Family). Rates effective thru 12/31/15.

Monthly Premium

___Individual $50.34

___Two-Person $98.73

___Family $152.38

Please select one: ___ New Enrollee

___Add Family Member

___ End Coverage

___Change Name/Address/Billing

Coverage Action

Please select one of the following reasons when changing family coverage: ___Marriage

___Birth/Adoption

___Divorce

___Loss of Coverage

Your Previous Plan Are you cancelling coverage with another Delta Dental of Rhode Island plan to enroll in the NEARI dental plan?

If yes, please provide the following information:

YES

___

Effective date of enrollment in the NEARI plan _________________. Previous group number ____________________.

Family Information If you’ve selected Family/Two-Person Coverage, fill in the appropriate information:

Spouse_______________________________/__________________

Child_______________________________/__________________

first name only

date of birth

first name only

date of birth

Child_________________________________/__________________

Child_______________________________/__________________

first name only

date of birth

first name only

date of birth

Coordination of Benefits

(Additional Dental and Medical Coverage)

Are you or any of your family members covered by another dental plan? ___YES

___NO

Is this an Individual____ or Family_____Plan?

(Check one.)

Other Dental Insurance Name:_________________________________

Other Dental Insurance Address:_________________________________

Policyholder Name:__________________________________________

Policy Number:_______________________________________________

Are you or any of your family members covered by a medical plan?

___YES

___NO Is this an Individual____ or Family_____Plan?

(Check one.)

Other Medical Insurance Name:________________________________

Other Medical Insurance Address:________________________________

Policyholder Name:__________________________________________

Policy Number:_______________________________________________

Method of Payment (See back for details.)

Please check

a payment type and fill in the appropriate information.

A. Direct Withdrawal from Bank Account:

Type:

__Checking

__Savings

Name on Bank Account:____________________________________________________________________________________________________

Bank Name:____________________________________

Bank Address:___________________________________________________________

Routing Number:________________________________

Bank Account Number:____________________________________________________

B. Credit Card:

Name: (exactly as it appears on Credit Card)____________________________________________________________________________________

Credit Card Type:

MasterCard

Visa

Credit Card Number:_______________________________

Expiration Date:___________

(MM/YYYY)

Authorizing Signature:

I certify that all information is true and correct to the best of my knowledge. I understand that the start date and cancellation date of my insurance coverage will be determined by Delta Dental of

Rhode Island. If I have selected Payment Method A or B, I authorize Delta Dental to withdraw funds from my bank account or charge my credit card no more than ten (10) days prior to the start of

coverage, and on a monthly basis thereafter. I understand that if funds/available credit balances are not available or payment is not otherwise timely made, I will no longer be eligible for coverage.

I have read and understand the information on both the front and back of this form.

Your signature (Form will not be processed without signature.)

Date

Please mail this form to Delta Dental of Rhode Island, P.O. Box 1517, Providence, RI 02901-1517.

10/10-1M