Form Delta 602a - Voluntary Enrollment Form - Delta Dental - California
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1Enrollment — Voluntary
Group Name
Delta Group/Division Number
A ENROLLEE
(Complete this section for new enrollment or change of status)
Name
Social Security Number
Date Employed
Action Requested
Please enroll me
in the following:
New enrollment
Reinstatement
COBRA enrollment
Transfer
Delta Dental
-
-
______________________________________________________________________
__________
__________
____________
______/______/______
Change in enrollment
Rehire
Delta Vision
Last
First
Middle Initial
(Member I.D. Number)
Month
Day
Year
Birthdate
Sex
Marital Status
Do you have
Employee Classification
Does your spouse have a dental plan?
Yes
No
Month
Day
Year
Single
dependent
If yes, who is covered:
yourself
spouse
Married
children?
Certificated
Full-time
Part-time
dependent children
Male
Divorced
Yes
Classified
Hourly
Retired
If Delta Dental, indicate group number: ________________________
__________/_________/__________
Female
Separated
No
Salaried
COBRA
FOR DELTA USE ONLY
Mailing Address _______________________________________________________________________________
Telephone Number (_______)____________________________________________________
City __________________________________________________________________________________________
State ________________________________________ ZIP code ________________________
COBRA Enrollment
I understand that I may be required by the employer to pay for COBRA benefits
Effective Date of Coverage
Note: If Dependent is enrolling under own social security number, the original Member’s social security number must be supplied.
Family Indicator Code
_______________________________________________________________________
Qualifying Date __________/_________/__________
Benefits previously received under Social Security Number (Member I.D. Number)
Month
Day
Year
B Change to Existing Enrollment
(Complete all sections that apply)
Name change
Add new dependent
Delete dependent
Address change listed above
Reason for change _________________________________________________________________________________________________________________
Effective date of change __________/_________/__________
Month
Day
Year
C DEPENDENTS
(Complete for new enrollment or to add or delete dependents)
Spouse Name
Add/
Sex
Birthdate
Marriage/Divorce Date
Spouse’s
Last (if different)
First
Middle Initial
Delete
M
F
Month Day Year
Month Day Year
Social Security Number
*
*
______/_____/_____
______/_____/_____
Child Name
If Child is 19 years or older
Add/
Sex
Birthdate
(check one)
Child’s
Last (if different)
First
Middle Initial
Delete
M
F
Month Day Year
Social Security Number
Full-time Student
Disabled
*
*
*
*
*
*
*
*
*
*
*
*
*
*
D Signature
(Form must be signed to be processed)
I understand that I may be required by the employer to pay for these benefits. I agree to continue membership in this program during employment and while the program is in force and I agree to comply
with the terms of the group contract.
Enrollee Signature _________________________________________________________________________________________________________________
Date ______________________________________________________
Delta 602A (4/96)
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