Enrollment Change Form

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Enrollment/Change Form
Delta Dental of South Dakota
Effective Date: __________________________
PO Box 1157
Pierre, SD 57501
Hire Date: _____________________________
(605)224-7345 Fax (605)224-0909
(800)627-3961
Group Name: __________________________ Group Number: ________
Employee Name: ________________________________________ SSN: _____________________
Employee Address: ______________________________________ DOB: _____________________
City/State/Zip: __________________________________________ Sex:
_____M
_____F
Phone Number: ______________________ Email Address: ________________________________
Marital Status
:
Single _____ Married ______
(common law marriage is not recognized in South Dakota)
*List only names of dependents you are enrolling:
First
Last (if different)
Sex
Birth Date
Add
S
POUSE
Drop
Add
CHILD
Drop
Add
CHILD
Drop
Add
CHILD
Drop
Add
CHILD
Drop
Add
CHILD
Drop
Please use additional sheet if you have more dependents.
CHANGE in Coverage
(Please list dependents you want removed from your plan in space provided above):
Marriage Date: ____________________________ Divorce Date: ____________________________
Other (explain): ________________________________________ Date of Change: _____________
**Signature: ________________________________________ Date: ______________
*I understand that should I decide to apply for single coverage, even though I am eligible for family coverage, I cannot
change my policy until open enrollment or a qualifying event (within the past 30 days). I also understand that Delta
Dental of South Dakota reserves the right to reject a change form.
**I accept the insurance provided by my employer’s group dental plan and authorize deductions from my earnings for
the required contributions, if any, toward the cost of the insurance. This authorization applies only if employee
contributions are required. I understand that by accepting insurance, I am required to remain enrolled as a covered
employee until the next open enrollment period, a qualifying event, or until the termination of my employment.
8/11

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