Form D-Ind - Delta Dental Iowa Individual Enrollment Change Application (Page 2 of 2) in pdf

Agreement and Certification

I certify that I am an Iowa resident and that I am legally authorized to apply for coverage for myself and/or for all other persons named

in this application. I understand that I am making application for individual coverage offered by Delta Dental of Iowa. I understand that

I am responsible to pay monthly premium charges to Delta Dental of Iowa for this coverage, and if payment is not made when due, my

coverage is subject to termination. I further understand that should this coverage be terminated, either voluntarily or involuntarily, I

will not be eligible to apply for individual coverage offered by Delta Dental of Iowa for a period of 24 months from the date of

termination unless I have had continuous coverage with similar benefits. I understand that coverage for the dental care policy applied

for will not start until after this application and the required monies for premium are received and accepted by Delta Dental of Iowa

and an effective date is established by Delta Dental of Iowa. I understand that written notice of rate changes will be furnished by Delta

Dental of Iowa at least 60 days prior to the effective date of any such rate change.

I certify that after this application was completed, I carefully and fully read it, that the statements and answers set forth are full, true, and

correct, to the best of my knowledge and belief, and that no information required to be given, either expressly or by implication, has

been knowingly withheld. I understand that Delta Dental of Iowa will rely upon the completeness and truthfulness of the information

given and the statements made, and that if I have made any false statements or misrepresentations, or have failed to disclose or have

concealed any material fact, Delta Dental of Iowa will be entitled to declare the dental care policy applied for void and refuse allowance

of benefits to any person thereunder.

I authorize any health care provider to release medical records to Delta Dental of Iowa when reasonably related to the dental care

coverage for which I have applied. If any law or regulation requires additional authorization for release of dental records, I will give this

authorization.

To cancel coverage, Delta Dental of Iowa requires written notice be received at least 20-days prior to the requested termination date

to ensure the automatic payments can be discontinued in a timely manner..

DELTA DENTAL OF IOWA

ACCOUNT WITHDRAWAL AUTHORIZATION - REQUIRED

I (we) hereby authorize Delta Dental of Iowa to initiate debit entries to the account indicated below, and the financial institution

named below, to debit the same to such account.

This authorization is for the purpose of paying monthly premiums for Delta Dental coverage. I understand that the amounts are

subject to change upon prior written notification to me at least 60 days in advance of any rate adjustment.

Monthly Withdrawal Date:

of month

Bank Information:

____________________________________

__________________________

Name of Financial Institution

Branch (if applicable)

______________________________________________________________________

Address of Financial Institution

City

State

Zip Code

Account Type:



Checking – please attach a voided check (deposits slips are NOT acceptable for checking account information)



Savings – please attach a pre-printed deposit slip and indicate for savings account only:

Bank Routing Number __________________ Account Number ________________

This authority is to remain in full force and effect until Delta Dental of Iowa has received written notification from me (us) of its

termination. Delta Dental requires written notice to be received at least 20 days prior to the requested termination date in order to afford

Delta Dental and the above named financial institution sufficient opportunity to process.

I certify to the best of my knowledge that the banking information given above is not that of a foreign banking institution (located outside of the

United States).*

_________________________

__________________________________

Please Print Name of Insured

Delta Dental ID Number

_________________________

_________________________________

Signature of Insured

Date Signed

*If your banking institution is a foreign bank, please contact Delta Dental of Iowa for further instructions.

Please sign & return both pages of the application with a voided check or pre-printed savings account deposit slip

D-IND (06-2013)

Form D-Ind - Delta Dental Iowa Individual Enrollment Change Application Page 2

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