Form 2013-060-Dd - Individual And Family Plan Enrollment (Page 2 of 2) in pdf

Please carefully read the Contract Provisions below. Signature required.

Contract Provisions

IMPORTANT: If you do not want the contract for any reason, you may return it to us within 10 days after you receive it.

Upon return, the contract will be deemed void, and any money you have paid will be refunded.This is an annual contract. If

you have elected the annual payment option, you may not terminate this contract prior to the end of the term. If you have

elected the monthly payment option and we do not receive your premium within 30 days of the date the premium is due,

your contract will be cancelled effective the due date of your premium, whether or not a specific condition was incurred prior

to the termination date. Your Covered Dependents will terminate on your termination date. Covered Services are eligible for

payment only if your contract is in effect at the time such services are provided.

I acknowledge that I have read the provisions of this enrollment form and I expressly accept such provisions as a condition of

coverage. I understand that my membership is for a 12-month period and on my anniversary date I can renew or cancel or

change how I pay my premium. I represent the answers given to all questions on this form are true and accurate to the best of

my knowledge and I understand they are being relied on by Delta Dental of Kentucky, Inc. in accepting this form. Any material

misrepresentation found in this application may result in denial of benefits or cancellation of my coverage(s). Any person who

knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any

materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits

a fraudulent insurance act, which is a crime. If accepted, this form, the dental contract, and the identification card will

constitute the contract.

Applicant Signature_________________________________________________________ Date _____________________

If Applicant is under the age of 18 at the time of enrollment, a parent or guardian must agree to the above conditions on

behalf of Applicant and must agree to assume financial responsibility for Applicant.

Agreed___________________________________________________________________ Date _____________________

Relationship to Applicant ___________________________________

You can enroll online at

Make a copy for your records and return original with payment to:

Delta Dental of Kentucky

c/o PlanChoice

13257 O’Bannon Station Way

Louisville, KY 40223

Delta Dental of Kentucky reserves the right to assign effective dates.

PRODUCER TO COMPLETE BEFORE SENDING TO DELTA DENTAL

Producer Name (printed)

Producer Number/SSN

Producer Phone Number

Producer Signature

Date

SHADED AREA FOR OFFICE USE ONLY

Effective Date

Process Date

Processed By

Underwritten by Delta Dental of Kentucky, Inc.

Form 2013-060-Dd - Individual And Family Plan Enrollment Page 2