Form Ddp-692 - Application And Change Form For Individual & Family Dental Insurance Page 2
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3PAYMENT INSTRUCTIONS
20. *SELECT ONE PAYMENT METHOD AND FOLLOW INSTRUCTIONS:
Please see enclosed rates or visit Premiums are due by the 20th of each month,
prior to the month of coverage.
PAYMENT METHOD 1
Please select coverage:
AUTOMATIC MONTHLY WITHDRAWAL
I I
Subscriber Only
$
FROM BANK ACCOUNT (AUTOMATED CLEARING HOUSE (ACH) PAYMENTS)
I I
Subscriber + One
$
ACH payments occur on the 20th of the month (or next business day) prior to coverage.
I I
Family
$
Please make your first payment by check payable to Delta Dental of Massachusetts.
Enclose it with this application and postmark it by the 20th of the month for coverage effective
the first day of next month. You must sign the Authorization Agreement and attach a voided check
to this application. All future payments will then be deducted from the bank account indicated below by Crosby Benefit Systems, Inc.
AUTHORIZATION AGREEMENT FOR ACH PAYMENTS
I authorize Crosby Benefit Systems, Inc., agent for Delta Dental of Massachusetts, hereafter named the COMPANY, to initiate recurring monthly
debit or credit entries to my (Checking Account / Savings Account) as indicated and named below as the depository financial institution, hereafter
named FINANCIAL INSTITUTION. I acknowledge that the origination of ACH transactions to my account must comply with the U.S. law. If any such
debit(s) is returned Non-Sufficient Funds, I authorize the COMPANY to collect that amount along with a Non-Sufficient Funds fee of $25.00 per item
by electronic debit from my account.
I am an authorized check signer on the account listed below, and authorize all of the above as evidenced by my signature below.
Financial Institution
Branch
City
State
Zip
Routing Number
Acct. Number
This authorization is to remain in effect until the COMPANY has received written notification from me of its termination
with 30 days notice.
Name
Signature
Date
PAYMENT METHOD 2
Please select coverage:
MONTHLY PREMIUM PAYABLE BY CHECK
Subscriber Only
$
I I
Make check payable to Delta Dental of Massachusetts with this Application and postmark it by
Subscriber + One
$
I I
the 20th of the month for coverage effective the first day of the following month. In the event
Family
$
I I
there are not sufficient funds to cover my check, I agree to pay a $25 Non-Sufficient Funds fee.
Name
Signature
Date
COVERAGE PERIOD
The initial term of your policy will be for one year from the Effective Date. After the initial term, this policy will renew automatically establishing a new
Effective Date each year until a Change Form is submitted or until this Agreement is terminated. This policy may be terminated upon thirty (30) days
written notice to Delta Dental of Massachusetts. Additionally, you must wait at least one year after your cancellation before you can enroll again
as a subscriber.
Delta Dental reserves the right to change premium rates upon renewal of the policy. Delta Dental agrees to keep your coverage in force as long as
you continue to pay the premiums on time and as long as you retain residency in the state of Massachusetts.
Applications postmarked by the 20th of the month will become effective the 1st of the following month. Examples: Applications postmarked
June 20 will have an Effective Date of July 1. Applications postmarked June 21 will have an Effective Date of August 1.
TERMS
By signing below, you verify that you have read and agree to the following:
• I UNDERSTAND THAT THERE IS A SIX MONTH WAITING PERIOD ON BASIC RESTORATIVE SERVICES AND A TWELVE MONTH WAITING PERIOD
ON MAJOR RESTORATIVE SERVICES. (May be waived for previous Delta Dental of Massachusetts group members who have no more than a
60 day break in coverage.)
• I confirm that all information is true and correct to the best of my knowledge.
NOTICE: Any person who purposely attempts to commit fraud or deceive an insurer by filing a false claim or an application with false, incomplete or
missing information is guilty of a third degree felony and will result in this policy being terminated.
21. *Subscriber Signature
Date
22. Will this policy replace an active dental insurance policy?
I I
No
I I
Yes (If Yes, please complete the Notice of Information
Practices form and include it with this application)
Side 2
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