Aetna Dental Ppo Max Insurance Plan Enrollment Form printable pdf download

Applying Is Easy. Here’s How:

Aetna Life Insurance Company

Underwritten by Aetna Life Insurance Company

1. Complete and Sign This Form.

151 Farmington Avenue • Hartford, CT 06156

2. Make Premium Check Payable to:

SPE Insurance Program

3. Mail Completed Form and Check to:

Aetna Dental

PPO Max Insurance Plan

SPE Insurance Program

Enrollment Form

P.O. Box 9159, Phoenix, AZ 85068-9159

Have a Question or Need Additional

Information? Please Call 1-800-337-3140

For Members of the Society of Petroleum Engineers

or E-mail: .

PLEASE PRINT IN INK OR TYPE ALL ANSWERS.

Member’s Name and Address:

Member’s Full Name: ______________________________________________________________________________________________

I I I I I I

I I I I

I I I I I I I I

LAST

FIRST

MIDDLE INITIAL

I I

Date of Birth: ________ /________ /________

Gender:

Male

Female

Social Security #:

MONTH

DAY

YEAR

____________________________________________________________________________________________________________

STREET ADDRESS

_____________________________________________________________________________________________________________

CITY

__________________________________________________Phone Numbers: ( ________ ) ____________________________________

STATE (OR PROVINCE)

HOME

________________________________________________

( ________ ) ____________________________________

ZIP CODE

WORK

Membership Affiliation:

I I

Are you now a member of the SPE?

Yes

What is your membership number, if available? __________________________________

Dependent Coverage Information for Plus One and Family Coverage:

I I

_________________________________________________________________ Gender:

F Relationship:

Spouse

Child

Name

Birth Date

Social Security #

I I

_________________________________________________________________ Gender:

F Relationship:

Spouse

Child

Name

Birth Date

Social Security #

I I

_________________________________________________________________ Gender:

F Relationship:

Spouse

Child

Name

Birth Date

Social Security #

I I

Select Coverage:

Member

Member + One

Family

Choose Your Payment Options:

(See reverse side for premium information)

I I

Please Bill Me:

Monthly

Quarterly

Semiannually

Annually

Premium Amount: ___________________________________

Please note: A $2.00 administrative fee is added for billing modes other than annual.

20210

I I

I Want to Pay by:

Check or Money Order

Monthly Bank Draft (Please enclose a voided blank check and complete deduction authorization.)

Please include your first month’s payment with your completed application. Make your check payable to SPE Insurance Program.

Deduction Authorization: I hereby authorize A.G.I.A., Inc., the SPE Insurance Program Administrator, to initiate monthly debit entries to my checking

account for payment of insurance premiums. This authority is to remain in effect until I cancel it by written notification to the Company at least 30 days in

advance of the intended termination date of my coverage. (Any excess premiums which may accrue after termination of my coverage will be refunded to me.)

________________________________________________

____________________________________________________

BANK NAME

BANK ROUTING #

_______________________________________________________________________________________________________

BANK STREET ADDRESS

CITY

STATE

ZIP

________________________________________________

__________________________________________________ _ __

CHECKING ACCOUNT #