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Refusal of Insurance:

If the plan requires contributions, and I have refused the insurance, I understand that if I request coverage for myself and/or my

eligible dependents at a later date, I will be required to furnish, at my own expense, proof of each person's insurability, and

Guardian reserves the right to reject my request. Proof of insurability does not apply to dental, but I will be considered a late

entrant and my dental benefits will be limited for specific periods of time. However, I and/or my dependents will not be subject to

late entrant penalties if dental coverage under another plan is being discontinued as a result of termination of another plan's

coverage, loss of employment, death of spouse, divorce, or where a court has ordered coverage be provided for an eligible

spouse or eligible minor child(ren), and application for this plan and documentation of the loss of other coverage is received

within 31 days of the termination of such coverage.

** The Pre-Paid dental plan refers to (a) DHMO's which are underwritten by Managed Dental Care of California or Managed

DentalGuard or; (b) Managed DentalGuard plans underwritten by The Guardian Life Insurance Company of America. Please

consult your Plan Administrator for the plan available to you. The late entrant provision does not apply to Pre-Paid dental benefits.

Eligibility for this coverage is only available at the open enrollment period.

Agreement:

I hereby (1) request coverage for the Group Insurance for which I am or may become eligible; (2) authorize my employer to make

the necessary deductions for the contributions, if any, required for coverage, or agree that the contributions be added to my dues;

(3) state that I became an employee, and do currently work the number of hours per week stated on this form; and (4) designate

the beneficiary named on this form to receive the proceeds, if any, payable in the event of my death. I understand that, in order to

be accepted for coverage, my signed and completed application for coverage must be received by Guardian within 31 days of my

eligibility for coverage. I authorize any provider, insurer, or other organization to release the necessary information regarding my

dental history, treatment or benefits to Guardian or its subsidiary or authorized agent, for the purpose of plan administration.

Form Gg-013374-L-D-Di-V - Enrollment/change Form - Life/dental/disability/vision - 2005 Page 2