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Individual And Family Dental Change Form (Start Date Of January 1, 2014 Or Later) - Arkansas Blue Cross And Blue Shield Page 3

9 ADDING SPOUSE OR DEPENDENT(S)

(Continued)

o Yes o No

Are all applicants permanent, legal residents of Arkansas?

If "no," please provide: Name: _________________________ Address: _______________________

Reason: _______________________________________________________

o Yes o No Have any of the proposed insureds had any other dental coverage within the last 12 months? If yes, list:

Name: __________________ Carrier Name: _______________ Effective Date: __/__/___ Termination Date: __/__/___

PLEASE READ BEFORE SIGNING

I UNDERSTAND: (1) This application may be rejected. (2) If accepted, the insurance applied for shall

not become effective until the date shown on my schedule of benefits and the adjusted premium,

if applicable, is paid in full. (3) If my application is accepted relying on my representations on this

document, any coverage which may be issued to me shall be invalid if based on false information. (4)

My signature authorizes Arkansas Blue Cross and Blue Shield to coordinate benefits under this policy

with other insurance I have which is subject to coordination. (5) Arkansas Blue Cross and Blue Shield

may phone me for additional information that may help with the timely processing of my application. In

signing below, I: represent that the statements and answers given in this application and any signed and

dated addendum to this application are true, complete and correctly recorded.

I certify that I signed this application in the state of Arkansas.

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to fines and

confinement in prison.

SIGNATURE SECTION (Please sign appropriate line only)

Current Policyholder

Date Signed

Parent/Legal Guardian's

(if policy for a minor)

New Policyholder

Date

For Home Office Use Only (Do not write in this space.)

Page 3

Form No. OE Dental CF (R12/15)

Individual And Family Dental Change Form (Start Date Of January 1, 2014 Or Later) - Arkansas Blue Cross And Blue Shield Page 3