Form 3400 Ca - Enrollment/change Form printable pdf download

ENROLLMENT/CHANGE FORM - CA

FOR GROUP USE ONLY

Delta Dental of California

6632

Group No.

Division

State

Hire

Effective

Date

Employee Classification

Name of Employer

Delta Dental of California

Los Rios Community College District

P.O. Box 429086

San Francisco, CA 94142-9086

Location

Pay Code

Benefit Package

VERY IMPORTANT - Please Print Legibly

Enrollee/Change Information

Enrollee Classification

New Enrollment

Marital Status Change

Terminate Enrollee Coverage

SSN/Enrollee ID Number Correction or

Full-Time

Hourly

Certified

previous ID under which benefits are received

Part-Time

Salaried

Classified

Add/Delete Dependent

Address Change

Other __________________

Retired

Member/Other _______________

Primary Enrollee Information

COBRA

(if applicable)

Social Security Number

Enrollee ID Number (if applicable)

Date of Birth

Gender

Marital Status

Termination

--------------------

Male

Female

Single

Married

Reduction in Hours

First Name

Last Name

Middle Initial

Divorce/Legal Separation*

Mailing Address (Street)

City

State

Zip Code

Widowed/Surviving Dependent*

E-mail Address (internal use only)

Phone Number

Phone Type

(

)

Dependent Child No Longer Eligible*

Cell

Work

Home

Name of Other Dental Carrier

Policy Holder Name (first/last)

Date of Birth

Indicate qualifying date: _____________________

*If a dependent is enrolling under his/her social

Policy Holder Street Address

City

State

Zip Code

Effective Date

security number, the SSN currently enrolled

under must be provided.

of Other Policy

Dependent Information

Relationship

Dependent First Name

(Last only if different from enrollee)

Add / Term

Social Security Number

Date of Birth

Male / Female

Student / Disabled**

Name of School (overage student)**

Spouse/Partner

Dependent

Please attach a separate sheet for additional dependent information. All dependents listed will be considered enrolled. **Additional documentation will be required for disabled and student status.

I authorize any payroll deduction that may be required towards the cost of this coverage. I certify that the above information is true and correct to the best of my

knowledge. I understand that changes can only be made if I experience a qualifying family status change, in which case the change must be consistent with that

event, or as may otherwise be provided by the group contract.

I decline coverage at this time.

Signature of Enrollee

Date

Form 3400 CA

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