Enrollment/change/waiver Form - Dental/vision
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1
2Delta Dental of Wisconsin
Enrollment/Change/Waiver Form - Dental/Vision
PLEASE NOTE THAT COMPLETING THIS FORM DOES NOT GUARANTEE COVERAGE.
EMPLOYER USE ONLY
DENTAL GROUP NUMBER
______________
______________
______________
______________
EFFECTIVE DATE
_________________________
VISION GROUP NUMBER
______________
______________
______________
______________
EFFECTIVE DATE
_________________________
COMPLETE THIS SECTION IF YOU ARE ACCEPTING, CHANGING, OR TERMINATING COVERAGE
EMPLOYEE LAST NAME
FIRST
M.I.
SSN OR EMPLOYER-ASSIGNED ID
DATE OF BIRTH (M/D/Y)
SEX
F
M
HOME ADDRESS - STREET
CITY
STATE
ZIP
EMPLOYER NAME
EMPLOYER LOCATION
CITY
STATE
DATE OF HIRE (M/D/Y)
PLAN SELECTION (NOTE: You may enroll dependents only in plans that you enroll in)
DENTAL
VISION
SELECT PLAN(S) YOU WISH TO ENROLL IN:
LIST ALL ELIGIBLE FAMILY MEMBERS TO BE COVERED
RELATIONSHIP
SPOUSE LAST NAME (IF DIFFERENT)
FIRST
M.I.
SON
DAU.
DATE OF BIRTH (M/D/Y)
DENTAL
VISION
DENTAL
VISION
DENTAL
VISION
DENTAL
VISION
DENTAL
VISION
DENTAL
VISION
DENTAL
VISION
REASON FOR SUBMITTING THIS FORM
COVERAGE TYPE
NEW ENROLLEE
REHIRE (Date: _____________________________)
WHAT TYPE OF DENTAL COVERAGE ARE YOU APPLYING FOR?
Date
IF THIS IS FOR CHANGE, WHAT IS THE REASON?
Employee Only
Employee & Spouse
Occurred
Employee & Child(ren)
Entire Family
Birth/Adoption (Name:________________________________)
_______________
Marriage/ Divorce
_______________
WHAT TYPE OF VISION COVERAGE ARE YOU APPLYING FOR?
Add/ Drop Dependent (Name: _____________________)
_______________
Employee Only
Employee & Spouse
Termination of Benefits (Reason: ______________________)
_______________
Employee & Child(ren)
Entire Family
Loss of Dental Benefits
_______________
Name Change (Former Name: __________________________)
_______________
YOUR MARITAL STATUS
Single
Married
Address Change (_____________________________________)
_______________
If you are not accepting coverage for your spouse or dependents,
Group Transfer (From _____________To _________________)
_______________
are they covered by another dental plan? Yes
No
COBRA Application
_______________
X
ACCEPT COVERAGE:
DENTAL
VISION
Signature is Required
Date
COMPLETE THIS SECTION ONLY IF YOU ARE WAIVING COVERAGE
IF WAIVING DENTAL
IF WAIVING VISION
EMPLOYEE LAST NAME
FIRST
M.I.
PLEASE CHECK ONE:
PLEASE CHECK ONE:
I have dental coverage through my spouse
I have vision coverage through my spouse
SSN OR EMPLOYER-ASSIGNED ID
EMPLOYER NAME
I have other dental coverage
I have other vision coverage
I do not have other dental coverage
I do not have other vision coverage
EMPLOYER LOCATION
CITY
STATE
X
WAIVE COVERAGE:
DENTAL
VISION
Signature is Required
Date
F708D-1411
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