Form Ddp-692 - Application And Change Form For Individual & Family Dental Insurance
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Application and Change Form for
Individual & Family Dental Insurance
P.O. Box 981400
Customer Service: (800) 872-0500
Boston, Massachusetts 02298-1400
Please print or type. Required fields are starred (*) and must be completed to ensure enrollment. Subscriber must be age 18 or older.
1. * LAST NAME:
2. *FIRST
(Subscriber)
NAME:
3. * SOCIAL
4. *DATE OF BIRTH:
5. *GENDER:
F / M
Male
SECURITY NO.:
6. * HOME
7. *CITY:
8. *STATE:
9. *ZIP:
ADDRESS:
10. * COUNTY:
11. *PHONE
12. *E-MAIL:
NUMBER:
ELIGIBLE DEPENDENT(S) TO BE COVERED UNDER THIS POLICY
If you are applying for Subscriber Only coverage, do not complete this section.
13. FIRST NAME
14. LAST NAME (if different from subscriber)
15. DATE OF BIRTH
SPOUSE
CHILDREN
16. Are you a former Delta Dental of Massachusetts member through an Employer plan or COBRA?
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No
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Yes
If yes, please provide former subscriber ID Number
Last Date of Coverage
REASON FOR SUBMISSION
17. * CHECK ONE:
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New Application
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Reinstatement
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Termination
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Change
IF TERMINATION OR CHANGE, PLEASE COMPLETE BELOW (CHECK ALL THAT APPLY):
Name
Phone Number
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Address
Email
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Coverage to:
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Subscriber Only
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Subscriber+One
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Family
Add dependent(s)
Name
Name
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Remove dependent(s)
Name
Name
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Please use a separate page for additional dependents to be added or removed from plan.
If changing plans indicate the new selection:
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Option 1
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Option 2
Payment method (You must complete section 20)
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Termination (Reason):
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Relocated out of Massachusetts
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Have other Dental Plan
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Other
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Non-payment
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Deceased
DELTA DENTAL PREMIER PLAN SELECTION
Please refer to the Summary Plan description to review your options
18. *SELECT ONE:
19. *SELECT ONE:
Option 1
Option 2
Age 50 and older
Under age 50
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To complete this application, you must select one payment option in section 20 and sign section 21 on side 2,
and mail items to Delta Dental, C/O Crosby Benefit Systems, P.O. Box 981400, Boston, MA 02298-1400
DDP-692 (11/10)
Side 1
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Parent category: Business