Dental Insurance Enrollment Application Form - University Of Arkansas printable pdf download

PO Box 15965

DENTAL INSURANCE

North Little Rock, AR 72231

501-835-3400

University of Arkansas

Fax 501-992-1890

ENROLLMENT APPLICATION

800-462-5410

Entire form must be completed. Coverage subject to approval

NEW ENROLLMENT:

Employee

Employee & Spouse

Employee & Child(ren)

Employee, Spouse & Child(ren)

CHANGE:

ADD (circle one or both) Spouse / Child

TERMINATE (circle all that apply) Employee / Spouse / Child

Important Notice: If you elect to drop any portion of your Dental coverage, you will not have the opportunity to add coverage again unless

you do so within 31 days of a qualified change of status event. The UA does not offer an annual open enrollment period.

I would like to pay on a pre-tax basis. I understand that any change I need to make to my dental benefits can only take

place within 31 days of a qualifying change of status event, in accordance with Section 125 regulations.

I would like to pay on a post-tax basis.

If neither box is checked, the current election will remain (or post-tax if new enrollment).

PART A: EMPLOYEE/SUBSCRIBER INFORMATION:

FIRST NAME ______________________________ INITIAL _______LAST NAME_______________________________ DATE OF BIRTH ____/____/___

Mo Day Year

STREET ADDRESS __________________________________________ APT # ________

DAYTIME PHONE NUMBER ____________________________

CITY ___________________________________ STATE ___________ ZIP ________________

SOC SEC NUMBER ___________________________

Single

Married

Gender:

Male

Female

MARITAL STATUS:

DO YOU CURRENTLY HAVE OTHER DENTAL COVERAGE _____

IF YES, COMPLETE THE FOLLOWING:

(Y/N)

POLICYHOLDER’S NAME _________________________________________________ NAME OF EMPLOYER ___________________________________

POLICY# ___________________________________________________ NAME OF CARRIER ___________________________________________________

PART B: DEPENDENT INFORMATION:

List the eligible family members you wish to enroll/add/delete.

Social Security

Date of Birth

Gender

Other Coverage?

Add

Drop

First Name

Last Name

Number

(Mo/Day/Year)

(M/F)

(Y/N)

Spouse

Child

EMPLOYEE SIGNATURE: _________________________________________________ DATE: ________________________

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false

information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

PART C: TO BE COMPLETED BY THE EMPLOYER:

Effective Date: _________________________

Campus:

UAMS

UALR

UAF

UAM

UAPB

UACCB

ASMSA

CES Other: ____________________

Group #: ______________________________

Applicant’s Hire Date:

____________________________________________

Original: Delta Dental

copy: U of A

copy: Employee

UACES010

UACES_010

Dental Insurance Enrollment Application Form - University Of Arkansas

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