Delta Dental Small Group Enrollment Application

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Small Group Enrollment Application
Delta Dental of Virginia
(New Enrollment/Changes to Enrollment)
4818 Starkey Road, Roanoke, VA 24018
(540) 989-8000 · (800) 237-6060
Fax: (540) 776-8109
IMPORTANT: Incomplete information will delay enrollment. Please print using a ball point pen, press firmly and print clearly.
Group Name:
Effective Date:
Group No:
Sublocation/Division No:
Section A: ENROLLMENT/CHANGE (For qualifying event provide date and reason in section D)
New Hire
ADD dependent/spouse
Coverage Change
Reinstatement
Open Enrollment
DROP dependent/spouse
COBRA (Effective Date ___/___/___)
Cancel Coverage
Change/Update Information
Name - Previous Name _______________________
Address
Telephone
Other_________________________
Decline Coverage - I understand that I have been offered and have elected to decline coverage under my employer sponsored dental plan with Delta
Dental at this time. I will not be eligible to enroll until the next open enrollment period or in the event of a qualifying event during the coverage period.
(Sign, date and complete first line of Section B.) Signature ______________________________________________
Date _______________________
Section B: EMPLOYEE INFORMATION
Last Name
First Name
MI
Social Security Number
Group Assigned ID (if applicable)
-
-
Mailing Address (#, Street, Apt)
City
State
ZIP
Home Telephone
Date of Birth
Gender
Marital Status
If married, will your spouse or dependents
have coverage under another group dental
Male
Single
No
Yes
plan on the date this plan becomes effective?
(
)
/
/
Female
Married
I agree to receive communications regarding my group plan via the email address that I have
Email Address
supplied on this application. If you do not want to receive communications about your policy via
email, please check this box
Date of Hire
Number of Hours Worked Per Week
Payroll Status
/
/
Section C: COVERAGE
Coverage Type (check one)
Product (check one)
Plan (if applicable)
Employee
Employee/Spouse
SM
®
Delta Dental PPO
plus Premier
DeltaCare
High Option
Employee/Child(ren)
Employee/Family
SM
Low Option
Delta Dental PPO
aXcess™
Employee/Domestic Partner (if offered under your dental plan)
®
Delta Dental Premier
Choice
Section D: LIST ALL MEMBERS TO BE ENROLLED (Check Reason for Change Below)
DELTACARE ONLY
Sex
Date of Birth
Last Name (if different)
First Name, MI
Relationship
(M/F)
(MM/DD/YYYY)
Dentist (First/Last Name)
Provider#
Add
Drop
Add
Drop
Add
Drop
Add
Drop
Date of Qualifying
Reason(s) for Qualifying Event
Marriage
Loss of other group coverage
Divorce
No longer dependent
Event
/
/
Birth or adoption
Death of spouse/dependent
Other ___________________________________________
Section E: AUTHORIZATION AND CERTIFICATION
I authorize dentists, dental office personnel, and other health care professionals and entities to disclose to Delta Dental of Virginia, its agents and employees
(including, without limitation, its claims and customer service personnel) all information necessary to determine (1) eligibility for coverage and (2) covered
benefits. This authorization is made for each individual to be enrolled or affected by this change. The authorization is valid for 30 months from the date this
form is signed for underwriting purposes. The authorization is valid for the term of coverage for the purpose of collecting information in connection with claims
for benefits. The applicant or the applicant’s authorized representative is entitled to receive a copy of the authorization form.
I understand that my selection of coverage may be changed only during the open enrollment period of each year unless I experience a qualifying event listed
under “Reasons for Change” in Section D. Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing false or deceptive statement may have violated state law. I certify that the information supplied by me on this form is
accurate to the best of my knowledge. Under DeltaCare, in the event you fail to select a dentist in the DeltaCare network, you hereby authorize Delta Dental
to select a dentist on your behalf so that your enrollment may be complete. You also authorize Delta Dental to change your selection, if you select a dentist
not in Delta Dental of Virginia DeltaCare network or your dentist no longer participates with the Delta Dental of Virginia DeltaCare network.
Signature: ____________________________________________________________________________
Date:_________________________________
EC#01.2012

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