Form D-Ind - Delta Dental Iowa Individual Enrollment Change Application
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1
2Individual Enrollment/Change Application
New Applicant
Change of Coverage
Name/Address Change
Please complete application and send to:
Delta Dental of Iowa
Email:
PO Box 9010
Fax: 1-888-264-1433
Johnston, IA 50131 – 9010
Customer Service: 1-877-423-3582 x3
Section I
Policyholder Information
Name (First, Middle Initial, Last)
Telephone No:
Status:
Single
Married
(
)
Other (Specify)_____________
Mailing Address – Street
City
State
Zip
E-mail address
Product Choice:
Requested Effective
Date:
___ /01/____
Preventive
Preferred Choice
st
Application must be received by Delta Dental of Iowa 20 days prior to the requested effective date. Effective date is always 1
of the
month.
Section II
Persons to be Covered (include Yourself if applying for coverage)
Social
Full-Time
Other
First Name
Middle Initial
Last( if different)
Security
Birthdate
Sex
College
Disabled
Dental
Number
Student
Status
Coverage
Self
Disabled?
M
No
___/___/__
Yes
F
Yes
Spouse
Disabled?
M
No
___/___/__
Yes
F
Yes
Disabled?
Eligible Child
M
Yes
No
No
___/___/__
School Name:
Yes
F
Yes
Disabled?
Eligible Child
M
Yes
No
No
___/___/__
School Name:
Yes
F
Yes
Disabled?
Eligible Child
M
Yes
No
No
___/___/__
Yes
School Name:
F
Yes
Other Dental Coverage
- If any person(s) on this application has dental insurance through another carrier where the employer
pays any portion of the cost or makes payroll deductions, please complete: Policyholder:_____________________________
___________________________________________________________________ ____/____/___
Single
Family
Name of other dental carrier
Policy Number
Effective Date
Contract type
Prior Dental Coverage
- Has any person(s) on this application had prior dental coverage within the past 60 days?
Yes
No
Note: Your previous coverage will be verified. Credit towards waiting periods may be given for those individuals that were covered
under a qualifying plan within the past 60 days. You will need to provide the following: verification of coverage on previous carrier’s
letterhead, coverage effective date and termination date, who was covered and listing of benefits.
Section III
Change of Coverage
Please check events requiring Contract changes:
Marriage
Death
Divorce
Birth/Adoption
Drop Covered Person
Terminating Benefits
Other (explain) ______________ Name of Affected Party ______________________ Date of Event ____________
Section IV
Agreement and Certification
I have read and understand the Agreement and Certification of Coverage language on the back of this application
and acknowledge receipt of a fully completed copy of this application.
ACCEPTANCE OF COVERAGE
_________________________________________________________
_____/_____/_____
Applicant Signature
Date
D-IND (06-2013)
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