Fillable Form Dd2-001 - Enrollment Change Form Delta Dental printable pdf download

(Please keep a copy for your records)

Check One:

New Application for Coverage

Enrollment/Change Form

Change Authorization

Waiver of Coverage (complete Section (6) ONLY)

EMPLOYEE

: (Please Type or Print Legibly)

Section 1

INFORMATION

Social Security / ID Number:

Group Number:

Employer/Group Name: (Please do not abbreviate)

Add

Terminate

Employee Name:

(First, Middle Initial, Last)

Male

Female

Email Address:

Home Address:

City:

State:

Zip Code:

Birth Date:

(mm/dd/yy)

Hire Date:

Effective Date:

Type of Medical Coverage:

Medical Carrier and Address:

(mm/dd/yy)

Single

Married

Single

Family

DEPENDENT

Section 2

INFORMATION

(List ONLY Eligible family members to be enrolled or affected by change)

Birth Date:

Action:

Spouse Name:

Effective Date:

(First, Middle Initial, Last)

(mm/dd/yy)

Add

Male

Terminate

Female

NOTE: If natural parents are separated or divorced, indicate name of parent with custody or who is legally responsible for health benefits:

Birth Date:

Action:

Dependent Name:

Effective Date:

(First, Middle Initial) (Last Name, if different)

Male

Female

(mm/dd/yy)

Add

Terminate

(mm/dd/yy)

Add

Terminate

(mm/dd/yy)

Add

Terminate

(mm/dd/yy)

Add

Terminate

(mm/dd/yy)

Add

Terminate

OTHER

Section 3

INSURANCE INFORMATION

(Complete ONLY if requesting coverage for dependent[s])

Spouse

Children

Dental Carrier:

Are your dependents covered by another dental plan?

Yes

Address:

Are your dependents covered by another medical plan?

Yes

Medical Carrier:

If YES, please provide spouse's Social Security #:_______________________

Address:

Spouse's employer:_______________________________________________

CHANGES:

Section 4

(Please mark all appropriate boxes that apply to change[s] you wish to make)

DELTA DENTAL OF KANSAS MUST BE NOTIFIED OF CHANGES WITHIN 30 DAYS OF EVENT

DATE OF EVENT:____________________________

Name Change:

From:___________________

To:__________________

Adoption/Legal Custody of Child

Marriage

Divorce

Other:

SIGNATURE / AUTHORIZATION:

Section 5

I hereby apply for group dental coverage for which I am eligible and authorize the release of dental records to Delta Dental of Kansas, Inc.

Authorization/Signature for Enrollment/Change[s]:______________________________

Date:______________________

WAIVER OF COVERAGE: (

Section 6

Complete ONLY if you or your family are not enrolling for benefits)

This is to certify that I have been given the opportunity to apply for group dental insurance available to me through my employer, and I have decided that I:

Do not want dental coverage for myself because:__________________________________________________________.

Do not want dental coverage for my spouse and/or my children.

I understand that in the event I should decide to apply for coverage at a later date, such subsequent application shall be conditional upon the approval of

Delta Dental of Kansas, Inc. and may be subject to waiting periods or limitations.

Authorization/Signature for Waiver of Coverage:_________________________________

Date:______________________

Printed-Employee Name:

____________________________________________

(First, Middle Initial, Last)

Social Security #:_________________

DELTA DENTAL OF KANSAS

P.O. Box 789769

Wichita, KS 67278-9769

(316) 264-1099 Fax (316) 462-3394

DD2-001 (02/15/10)