Enrollment Form For Ncrgea - Metlife Group Dental Coverage
ADVERTISEMENT
1ENROLLMENT FORM FOR NCRGEA - METLIFE GROUP DENTAL COVERAGE
Group Name:
Group Number:
NORTH CAROLINA RETIRED GOVERNMENTAL EMPLOYEES’ ASSOCIATION
104057-110108
(TO BE COMPLETED BY NCRGEA MEMBER - PLEASE PRINT LEGIBLY)
Directions:
DO NOT WRITE IN THIS AREA
1. Complete all responses. Incomplete forms cannot be processed.
FOR OFFICE USE ONLY
2. This form must be signed to be processed.
(TO BE COMPLETED BY NCRGEA)
3. After the first premium deduction is made, a dental insurance membership card
and a benefits booklet will be mailed to you.
Based on the coverage chosen,
the dental premium deduction
Name:______________________________________________________________
will be $____________PER MONTH
(Last)
(First)
(Middle Initial)
Address:____________________________________________________________
The first premium deduction will
City:________________State:_______ Zip Code:___________________________
be made on
__________________25, 201___
Social Security Number:_______________________________________________
If the dues are not currently
Date of Birth (Mo/Day/Yr):______________________________________________
being deducted, the first dues
deduction will be made on
Home Telephone Number (Include Area Code):_____________________________
__________________25, 201___
Alternate Telephone Number (Cell or Work):_______________________________
for a dues renewal date of
_________________, 201___
Email address:_______________________________________________________
Based on the yearly dues of
$_________, the dues deduction
will be $___________ PER MONTH
I wish to authorize monthly deduction of both my membership dues and deduction of dental premiums. If your NCRGEA
membership dues have been paid for the current year, we will begin your dues deduction the month prior to your next
scheduled renewal date. Dues are based on monthly income (see enclosed membership enrollment card for the scale).
My annual dues are:
_______ $11 ($ .92 monthly) _________ $17 ($1.42 monthly) __________ $25 ($2.09 monthly)
PLEASE MARK ONE BOX BELOW TO SELECT THE DENTAL PLAN DESIRED:
Member Only Coverage
Member and Spouse
Member and Dependent*
Member and Spouse and Dependent*
* Dependent: Children may be covered until their 26th birthday.
IF SPOUSE AND/OR DEPENDENT COVERAGE HAS BEEN SELECTED, PLEASE FILL OUT THE FOLLOWING:
Spouse’s Name: ______________________________________________ Date of Birth: ____________
Name of Child(ren):____________________________________________ Date of Birth: ____________
_____________________________________________ Date of Birth: ____________
_____________________________________________ Date of Birth: ____________
PAYROLL DEDUCTION AUTHORIZATION:
I received and read a copy of NCRGEA’s current description of the group dental plan insured and administered by Metropolitan
Life Insurance Company. If I qualify for payroll deduction, I agree to remain in the NCRGEA Dental Plan until December 31, 2017.
By signing below, I declare that all the information given in this enrollment form is true and complete to the best of my knowledge
and belief. I hereby authorize the North Carolina Retirement System to deduct from my retirement account both my
membership dues and/or my monthly dental plan premium as I’ve indicated above. This authorization applies to such
coverage until I rescind it in writing.
Signature:
_________________________________________________________________ ______________________
Member’s Signature
Date (Mo/Day/Yr)
If you have questions about this plan and/or the plan’s coverage, please call toll free at 1-800-356-1190.
Mail the completed enrollment form to:
NCRGEA, PO Box 10561, Raleigh, NC 27605-0561
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business