Form Gg-014289-Ny - Enrollment/change Form - Dental

Wholly Owned Subsidiaries:

Please Print clearly in Black or Blue ink

(see paragraph "Pre-Paid Dental" on reverse side)

ENROLLMENT/CHANGE FORM

Managed Dental Care (MDC) (CA)

Please Print in Capital Letters only

Managed DentalGuard (MDG) (TX, NJ)

DENTAL

The Guardian Life Insurance

(For Plans in MI see (h) on reverse side)

First Commonwealth (FCW) (IL, MO, IN, WI)

Company of America

Planholder Name (Company Name)

Group Plan Number

Division Class

PLEASE CHECK APPROPRIATE BOX

Initial Enrollment/Refusal of Coverage

Add Employee/Dependents

Drop/Refuse Coverage

Information Change

(Complete Sections 1, 3, 4, 6)

(Complete Sections 1, 3, 5, 6)

(Complete Sections 2, 4, 6)

(Complete Section 6)

Drop Employee (Complete Section 4)

Drop Dependents (Complete Section 4)

Add Employee

Add Spouse

Add Children

The date of withdrawal cannot be prior to the date this form is completed and signed.

Newborn

Termination of Employment *

New Hire

Marriage Date _____ /_____ /_____

Previously refused this coverage

Retirement

Previously refused this coverage

Adoption Date _____ /_____ /_____

Last Day Worked _____ /_____ /_____

Loss of Other Coverage

Last Day of Coverage _____ /_____ /_____

(Complete Section 5 if applicable)

Other __________________________________________________________________

SELECT COVERAGE:

REFUSE/DROP COVERAGE:

LOSS OF OTHER COVERAGE:

Dependents can only be enrolled in the

(See Refusal on back)

same coverages as selected by the employee.

Dental

I and/or my dependents were previously covered under

Employee

Spouse

Child(ren)

another group plan. Loss of coverage was due to:

Dental

Employee

Spouse

Child(ren)

I have been offered the above coverages and wish to refuse/

Termination of Employment

______ /______ /______

drop enrollment for the following reasons:

(

)

Divorce

______ /______ /______

Select

lndemnity

PPO

Buy-Up

DNO

Covered under another insurance plan and/or coverage.

One

Pre-Paid (MDC; MDG; FCW) (PPD; DHMO)

Death of Spouse

______ /______ /______

(You must select a primary care dental office for the

Other ______________________________________

Pre-Paid Dental option. Complete Pre-Paid Dental

Term./Expiration of Coverage

______ /______ /______

Office # in Section 6)

(additional information may be required)

Pre-Paid Dental Office #

Last

First

MI Sex

Birth Date

Social Security Number

(MM DD YYYY)

(See directory)

Add Drop

Emp.

M F

Name

Street address

City

State ZIP

Marital Status:

Single

Married

Divorced

Legally Separated

Widowed

Home Phone: (

)

Are you: Actively at work

Occupation/Job Title:

Retired

Other _________ (additional information may be required)

Date of Full Time Hire

Number of hours worked per week:

(MM DD YYYY):

Pre-Paid Dental Office #

Last

First

MI Sex

Birth Date

Social Security Number

Student

(MM DD YYYY)

(See directory)

Add Drop

Spouse

M F

Name

Child

M F Y N

Name

Child

M F Y N

Name

Child

M F Y N

Name

Child

M F Y N

Name

Have you included stepchildren?

Yes

No Are they dependent upon you for support and maintenance? Yes No

Is this your first eligible child? Yes No If "no," please list all eligible

children above.

What is your primary language?

Do you have a disability which would affect your ability to communicate or read? Yes No

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals

for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand

dollars and the stated value of the claim for each such violation.

Signature: __________________________________________________________________

Date

(MM DD YYYY)

GG-014289-NY (2/05)