Form 2013-060-Dd - Individual And Family Plan Enrollment printable pdf download

Individual and Family Plan – EHB Certified

Enrollment Form

Please select the plan in which you would like to enroll.

Requested Effective Date _______________

Delta Dental PPO

Delta Dental Premier

Applications received by the 20

of the month

are effective the 1

of the following month.

Please complete the information below. You must be a Kentucky resident to enroll.

Social Security Number

Name – Last

First

Home Phone

(

)

Date of Birth

Sex (Circle one)

Home Address – Number and Street

City

State

Zip

DAY

M or F

Email Address

Check the type of contract and list all covered dependents below, if applicable:

Single contract

Single plus Spouse/Domestic Partner

Single plus Child(ren)

Family

COVERED DEPENDENTS

List all Covered Dependents below. If additional space is required, attach a list to this form.

Date of Birth

Sex

Last

First

SSN Required

DAY

Spouse/Domestic Partner

Dependent

Dependents covered through the end of the benefit period in which they turn age 26.

Have you had prior coverage through a Delta Dental plan within the last 60 days? If yes, please include a copy of your Delta

Dental identification card or other proof of prior Delta Dental coverage.

Please select one of the payment methods below. Please provide all necessary information.

Paper Check or Money Order –

Credit Card –

Annual

Monthly

Annual premium only

Visa

MasterCard

American Express

Discover

Please include your check or money

order with this form.

Card Number ______________________________________________

Expiration Date _____________________________________________

Signature _________________________________________________

Annual credit card payments will be automatically withdrawn from

your account at your renewal.

Bank Draft – Monthly premium only

A) Please complete the enclosed “Did You Know?” authorization form or send a voided check with this form in order to

accurately establish your new withdrawal. The draft process will originate from our office between the 4th and the 6th of each

month and should reach your account for processing within three working days.

B) Monthly bank drafts will remain in full force and effective until Delta Dental of Kentucky and your bank (depository) have

received written notification from you of termination and in such time and in such manner as to afford the depository a

reasonable time to act on it.

Please carefully read the Contract Provisions on the back of this form. Signature required.

2013-060-DD

® Registered Marks Delta Dental Plans Association

(DD Process Rev. 9/14)

Underwritten by Delta Dental of Kentucky, Inc.

Form 2013-060-Dd - Individual And Family Plan Enrollment

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