Delta Dental Ppo Application Form Instructions
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DELTA DENTAL PPO Application Instructions
There are two forms:
1. Delta Dental application form
2. California Employers Alliance form.
Please fill out both forms, and sign & date each. Enclose a check or money order for the first
month's premium, payable to National Benefit Services. After the first month you will be billed
on a monthly basis. At this time there is no auto-pay available
.
Mail your forms and check to:
Rates
(make check payable to National Bene fit Services)
Delta Dental
Enrollees
PPO
Aquarius Insurance Services
Individual
$49.00
Attn: Michael Grodsky
+ Spouse
$87.02
3834 Roxton Ave.
+ Children
$99.95
Los Angeles, CA 90008
+ Family
$141.23
HOW TO FILL OUT THE TWO FORMS
Important: please use a black ballpoint pen and print very clearly!
Delta Dental Enrollment form
Section A
1. Put your name as ENROLLEE, and fill Social Security #, date of birth, gender, Marital Status,
Do you have dependent children?, Spouse dental plan.
2. Action Requested: check "New Enrollment"
3. Plan Type: check the box for Delta Dental (do not check the box for "vision").
4. Employee Classification: leave this section blank
5. COBRA: leave this section blank
Section B: leave this section blank
Section C – Dependents: Add your spouse, your partner, or dependents if they are enrolling.
Section D – sign & date
---------------------------------------------------
California Employers Alliance form
1. Plan Sponsor: Your name
2. Sponsor's Address: Your address, phone, email.
3. Type of business, years in business, and number of employees: leave blank
4. At bottom, sign & date on Plan Sponsor line.
What is the California Employers Alliance form?
The California Employers Alliance has a bargaining agreement with a union (United Industrial Service
Workers of America, or UISWA), which allows its members to have access to dental and health plans.
To obtain the dental or health insurance plan you are required to join the California Employer Alliance.
There are no additional fees. Everything is included in your monthly premium. You are not directly joining
a labor union.
Aquarius Insurance Services
Michael Grodsky, founder
3834 Roxton Avenue
office: (323) 293-6800 fax: (888) 241-2127
Los Angeles, CA 90008
CA insurance license 0F43491
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