Fillable Delta Dental Of Minnesota (Page 2 of 2) in pdf

Delta Dental Of Minnesota Page 2

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Employee Electronic Signature Usage Agreement:

When electronic signatures are used, federal law requires that we inform you of the following:



By checking the boxes below, I consent to electronic processing of this application to

include use of my electronic signature.



I acknowledge that Electronic Signature means that I am the person identified on this

application as the applicant, that I voluntarily accept all the terms and conditions as

stated in this application, and that I agree to the electronic processing of this record. I

acknowledge that my electronic signature will have the same legal effect as a signature

on paper.



I acknowledge that I have the right to print and keep this application on paper.



I acknowledge that I have the right to withdraw my consent to the electronic signature on

this application. I understand I must notify my benefit providers in writing of my

withdrawal of consent and that such withdrawal will not affect actions already taken by

my benefit providers.



I acknowledge that my consent to the use of my electronic signature applies to this

application only and not to any other transactions with my benefit providers.

I hereby apply for coverage on the basis of the statements and answers to the questions herein.

I hereby declare all answers to be true to the best of my knowledge and to accurately represent

the health of those persons applying for coverage and waiving coverage. I understand that

these statements, answers and subsequent information I provide are the basis for my coverage.

Furthermore, I understand that this application must be updated by me to include any condition

of disease which may occur between the date of my application and the Effective Date of

Coverage. I understand that if my application for new or additional coverage is accepted, that

applicable coverage will not be effective until after I am notified for the Effective Date.

I Agree

Employee Enrollment Acceptance:

I UNDERSTAND THAT PROVIDING FALSE INFORMATION OR OMISSION OF RELEVANT

INFORMATION IN THIS APPLICATION MAY RESULT IN THE DENIAL OF CLAIMS OR

CANCELLATION OR RESCISSION OF COVERAGE.

I Agree to the terms above

I understand that typing my full name on the space below serves as my electronic

signature and I have agreed to the terms explained in the above paragraph.

Signature:____________________________ Date:_________________

Delta Dental Of Minnesota Page 2

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