Form Pre-Enr-1081 - Employee Enrollment/change Form printable pdf download

EMPLOYEE ENROLLMENT/CHANGE FORM

Use this form for a new enrollment or a change to an existing enrollment. Please complete in blue or black ink.

Mail to: Premier Access Membership Accounting, P.O. Box 659020, Sacramento, CA 95865-9020 or fax to: 877.648.7748



Group Number:

Coverage Type:

PPO

DHMO

Effective Date of Enrollment/Change:

Reason for Enrollment Form



New Enrollment/New Hire



Qualifying Event

(Attach supporting documentation)

Change of Address



Late Enrollee



(Subject to Late Enrollee Waiting Period)



Terminate Dental Coverage, Subscriber & Dependent(s)

Add Dependent (including spouse and registered



Terminate Dental Coverage, Dependent(s) Only

domestic partner)

Qualifying Event: _______________________________

Change in Other Dental Insurance



(Please see reverse side)

Date of Qualifying Event: _________________________

Other (

)



Specify:

___________________________________

Subscriber (Employee) Information

Social Security Number:

Date of Hire:

Last Name:

First Name:

MI:

Street Address:

City: _______

State:

Zip:

_____________

Home Phone: (

)

E-mail Address:

Date of Birth:

Sex:

 M  F

Married?

 Yes

 No

Children?

 Yes  No

Employer (Company) Name:

Job Title:

Division/Class:

Hours Worked Per Week:

Preferred Spoken Language:

Preferred Written Language:

Ethnicity (optional): ______________

Race (optional):

DHMO Only: Please select a Primary Care Dentist (PCD) from the provider directory for yourself and each of your family members. Fill in

the Provider ID number and Office ID number in the appropriate areas. If a selection is not made, a PCD will be assigned for you.

Primary Care Dentist No.

Primary Care Dentist Office No.

Dependent Information

New Enrollment/New Hire: Complete this section for all dependents you are choosing to enroll.

Add Dependent: Complete this section only for the dependents you are adding to your existing enrollment.

Terminate Dependent Coverage Only: Complete this section only for dependent(s) you are choosing to terminate.

Primary Care

Sex

Primary Care

Relation to Subscriber

Last Name

First Name & MI

Date of Birth**

Dentist Office

(M/F)

Dentist ID #

ID #

Spouse/ or Reg. Domestic

Partner

Child

** Dependent child eligibility requirements are defined by the Employer Group Policy. Supporting documentation of dependent eligible status must

be submitted with this form for dependent children age 19 or over for the enrollment to be processed and claims paid.

To the best of my knowledge or belief, I have answered truthfully and completely the information requested on this application, including the

information on the back of this application. I understand that Premier Access Insurance Company reserves the right to rescind or terminate

coverage if any material misrepresentation is made in this enrollment application. I have read and agree to the notice on the back of this form.

MANDATORY BINDING ARBITRATION: Premier Access Insurance Company uses binding arbitration to settle disputes, including to settle claims of

dental malpractice. The insured understands and agrees that if a dispute arises in connection with this policy, the parties waive the right to a jury trial

and must settle the dispute through binding arbitration. The Premier Certificate of Insurance contains a provision that further addresses this issue

Premier Access Insurance Company does not use binding arbitration in connection with any dispute that an insured’s life insurance coverage.

Employee Signature:

Date:

01-14

PRE-ENR-1081

Form Pre-Enr-1081 - Employee Enrollment/change Form

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