Enrollment/change Request Form - Delta Dental
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1
2Enrollment/Change Request
Employer Group Information – To be completed by Employer
Group Name
Group Number
Sublocation/Store location
__________________
________________
__________/_________
(A)
Type of Activity – To Be Completed by Employer. Refer to instructions on back before completing this form. Print clearly.
1.
Enrollment
(
) New Enrollee / Subscriber
Effective Date ___/___/___
Date of Hire ___/___/___
2.
Change – Check all that apply
Date of Event
Reason
3.
Remove or Terminate – Check all that apply
Effective Date Reason
( ) Add Spouse
__/__/__
_______________
( ) Remove Spouse*
__/__/__
_____________
( ) Add Domestic Partner
__/__/__
_______________
( ) Remove Domestic Partner*
__/__/__
_____________
( ) Add Dependent Child
__/__/__
_______________
( ) Remove Dependent Child*
__/__/__
_____________
( ) Name Change
__/__/__
_______________
( ) Employee Withdrawal/Termination
__/__/__
_____________
( ) Change Plan
__/__/__
_______________
NOTE: Employee must be enrolled for spouse/dependents(s) to have
( ) Other
__/__/__
_______________
coverage.
( ) Add/Change Office ID Numbers
__/__/__
_______________
*Please complete Add/Change/Remove and Name columns in Section D.
4. Continuation of coverage, i.e. COBRA, State, total disability. Not all options are available or applicable. Contact Employer for available options.
Coverage for:
( ) Employee
( ) Dependents
Length of Continuation:
( ) 12 months
( ) 18 months
( ) 29 months
( ) 36 months
( ) Total Disability* Attach proof of total disability
Date of Loss of Coverage:
__/__/__
Date of Qualifying Event:
__/__/__
Billing:
( ) Home
( ) Group
(B)
Employee Information – Complete Sections (B-G)
Last name, First name, MI ___________________________
Social Security Number ______________________
Home Telephone ____________________
E-mail Address ____________________________
Home Address ________________________________
Apt # ____
City, State _________
Zip Code ______
Employer Name _____________________________
Work Telephone ______________________________
Work Address ____________________________
City, State ______________
Zip Code ______________
Date of Employment __/__/__Hours Worked per week ________
®
(C)
Plan Option – Your selection must be offered by your Employer Check one: ( ) Delta Dental Premier
( ) Delta Dental PPO
( ) Advantage Program
SM
®
( ) Delta Dental PPO plus Premier
( )
DeltaCare
(D)
Individuals Covered – List individuals for whom you are adding/changing/removing coverage. Attach sheet to list additional children. (Attach proof if
full-time post-secondary student. Attach proof of disability.)
(A) Add
Last Name
Sex
Birthdate
Social
Other
Previous Coverage
(C) Change
First Name, MI
M F
MM/DD/YYYY
Security
Health
Check if Yes
(R) Remove
Number
Coverage
Employee
_________
__________________
____
__/__/____
____________
_____________
_______
Domestic Partner
(If Coverage offered)
_________
__________________
____
__/__/____
____________
_____________
_______
Spouse
_________
__________________
____
__/__/____
____________
_____________
_______
Child
_________
__________________
____
__/__/____
____________
_____________
_______
Child
_________
__________________
____
__/__/____
____________
_____________
_______
Child
_________
__________________
____
__/__/____
____________
_____________
_______
Child
_________
__________________
____
__/__/____
____________
_____________
_____
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