Enrollment/change Request Form - Delta Dental Page 2
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1
2(E)
Other/Previous Insurance
Is your spouse employed?
( ) Yes
( ) No
If “Yes”, give name and address of your spouse’s employer.
__________________________________________________________________________________________________________________________
If “Yes” to Other Health Coverage (Section D), give names & policy numbers of insurance carrier, HMO, or other source. If enrolled in Medicare Parts A and/or
B, identify the coverage and provide the Medicare ID#.
__________________________________________________________________________________________________________________________
If “Yes” to Previous Coverage, identify names(s) of persons, give effective date and date coverage terminated, name of previous carrier and plan number.
__________________________________________________________________________________________________________________________
(F)
Dependent Information
Does any dependent listed in Section D live at a different address than the Employee? ( ) Yes
( ) No If “Yes”, who and at what address?
__________________________________________________________________________________________________________________________
Explain the circumstances
__________________________________________________________________________________________________________________________
If any dependent’s last name differs from yours, explain the circumstances.
__________________________________________________________________________________________________________________________
(G)
Employee Signature If you have questions concerning the benefits and services provided by or excluded under this Agreement, contact a Customer Service
Agent at 1-800-452-9310 before signing this form.
I represent that all the information supplied in this application is true and complete. I hereby agree to the conditions of enrollment on the reverse side of
the employee enrollment/change request. I authorize deductions from my earnings for any required contributions.
Employee Signature – Required _______________________________________
Date __/__/__
E-mail Address _____________________________________________
(H)
Employer Verification – To be Completed by Employer
Employer Signature – Required _____________________________________
Title __________________________________
Date __/__/__
Instuctions
Employer
Section (G) – Dependent Information
*Complete the Employer Group Information in the upper left corner of the form.
•
Complete this section for all new enrollments or coverage changes.
*Section A - Type of Activity:Check boxes indicating reason(s) for submitting application.
Section (H) – Employee Signature:
*Complete Section (H) – Employer Verification (in the upper left corner of the second page)of the form.
•
Complete this section for all new enrollments, coverage changes and terminations.
*Employer must complete this section for all new enrollments, coverage changes and terminations.
•
Employee must sign and date the Enrollment/Change Request Form in order for it to be processed.
*Employer must sign and date the Enrollment/Change Request in order for it to be processed.
Section (I) – Employer Verification
•
Employer must complete this section for all new enrollments, coverage changes and terminations.
Employee – Complete Sections (B-G)
•
Section (B) – Employee Information
Employer must sign and date the Enrollment/Change Request Form in order for it to be processed.
•
Conditons of Enrollment
Complete all information in order for your application to be processed.
Application Acknowledgment and Agreements
Section (C) Plan Option:
1.
On behalf of myself and the dependents listed on the reverse side I agree to or with the following:
Check one Plan option box ( ) Delta Dental Premier ( ) Delta Dental PPO
a)I authorize the sources stated below to give Delta Dental of New Jersey, Inc. or any consumer reporting
( ) Delta Dental POS
( ) Delta Dental PPO Advantage Program
( ) DeltaCare
agency acting on its behalf, information about me and my minor childern, if applying for coverage. Such
Select only an option offred by your employer.
information will pertain to employment, other health coverage, and medical advice, treatment or supplies
Section (D) – Individuals Covered:
•
for any physical or medical condition. Authorization sources are any physician or medical professional; any
Add/Change/Remove – Use “A”,“C”,or”R” to indicate wqhether you are adding,changing or removing
hospital, clinic or other medical care institution; any carrier, any consumer reporting agency; any
coverage for an individual.
employer.
•
Print your full name along with the name(s) of your dependents, if applicable. Indicate
b) I understand that I may revoke this authorization at any time. I agree that such revocation will not
Sex,Birthdate,and Social Security number for each individual listed.
afect any action which Delta Dental of New Jersey, Inc. has taken in reliance on the authorization. I
•
If a dependent is a full-time post-secondary student, you must attach a current course schedule or a
understand this authorization will not be valid after 30 months, if not revoked earlier.
letter from the school or its authorized representative confirming full-time student status. If
c) I know that I have a right to receive a copy of the authorization if I request one.
dependent is disabled and being contiuned beyond the limiting age, attach proof of disibility.
d) I agree that a photocopy of this authorization is as valid as the original.
•
If you or your dependent(s) have other Health coverage, check off the “Yes” box(es) and complete
2.
I acknowledge by enrolling in a Delta Dental of New Jersey, Inc. plan or group policy coverage is provided
Section (F) – Other/Previous Insurance.
by Delta Dental of New Jersey, Inc. in accordance with the contract.
•
From the appropriate provider directory, locate the office ID number for the dentist (if applicable).
3.
Enrollment of myself and of the listed dependents into the plan is effective on acceptance by Delta Dental
Indicate office ID number selection(s) on the form.
of New Jersey, Inc.
Section (E) – Pre-Existing Conditions Statement
4.
Coverage and benefits are contingent on timely payment of premiums and may be terminated as provided in the
•
Complete this section for all new enrollments. Exceptions: For Small Employer Group coverage, this
plan documents. My employer is hereby authorized to withhold payments from my wages, as appropriate.
Misrepresentation
section must be completed only by persons enrolling in the group coverage in a group of 2-5 employees
5.
Any person who includes any false or misleading information on an Enrollment/Change Request form for a
and by late entrants.
Section (F) – Other/Previous Insurance
health benefits plan is subject to criminal and civil penalties.
•
Complete this section for all new enrollments or coverage changes. Coverage includes group coverage,
CC 07/09
governmental coverage, a church plan or Medicare.
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