Enrollment Form (Page 2 of 2) in pdf

NEARI MEMBER DENTAL PLAN

P.O. BOX 1517

Providence, RI 02901-1517

800-843-3582

Please read the following information regarding the plan’s eligibility, coverage and payment guidelines.

Eligibility Information

You must be a NEARI member to qualify and remain eligible for coverage. If you suspend your membership with this association, your dental

coverage is subject to termination.

Coverage Type and Premium

Delta Dental offers Individual, Two-Person and Family Coverage. Enrollment in this program is on a monthly basis. Rates are guaranteed for the

entire coverage period. Prior to the end of a coverage period, Delta Dental will mail a notification to you indicating any change in rates.

Enrollment and payment of premium is not a guarantee of claim payment. To be covered, services must be dentally necessary and in accordance

with Delta Dental’s treatment guidelines. All services must be performed in a dental office and the patient must be covered by a Delta Dental contract

on the day services are completed. You are not covered for major restorative benefits until you have been enrolled in the program for six

months. There are no refunds of premium dollars for this coverage.

Renewal of Coverage

Your coverage is automatically renewed at the end of your coverage period. Your coverage period is from your coverage start date until the end of

the calendar year, unless otherwise noted.

If you choose to end your coverage, you must notify us in writing. Cancellation of coverage is effective on the last day of your most recent payment

period, depending on the frequency of your payment (e.g. monthly, quarterly). Please Note: If you cancel coverage, you must wait 12 months

to reapply. If your new application is accepted, your coverage will begin on January 1 of the following year. Delta Dental reserves the right

to cancel coverage after appropriate notification due to non-payment of premium.

Family Information

If you are electing Family Coverage, please provide the first name and date of birth for each family member to be covered by this plan. List your

spouse first (if applicable) and then list your children. Dependent children are covered up until the end of the year that they turn age 19. Dependent

children who are full-time students over age 19 are covered as long as they stay in school or up until the end of the year in which they turn age 26.

Coordination of Benefits

(Additional Medical and Dental Coverage)

Please provide Delta Dental with any other medical or dental plan that covers you or your family member(s).

Method of Payment

This is a pre-paid dental insurance plan. Delta Dental offers two convenient payment options.

A.) Direct Withdrawal from Bank Account

– You may elect to have funds

withdrawn from your bank account monthly. Funds will be withdrawn no more than

ten (10) days prior to the start of coverage, and on a monthly basis thereafter. Please

use this sample check as a guide when selecting direct withdrawal from your checking

account. Please Note: Transactions that are returned for insufficient funds are

subject to a $25 processing fee.

B.) Credit Card

– You may opt for Delta Dental to charge your credit card monthly.

Your credit card will be charged no more than ten (10) days prior to the start of

coverage, and on a monthly basis thereafter. Please Note: Transactions that are

declined are subject to a $25 processing fee.

Authorizing Statement

Please read the authorizing statement on the front of this enrollment form and sign/date it. Delta Dental cannot process forms without an authorizing

signature. You will receive your Subscriber ID card and benefit literature approximately 15 days before your coverage begins.

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

Enrollment Form Page 2

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