Group Dental / Vision Application printable pdf download

NATIONAL GUARDIAN LIFE INSURANCE COMPANY

GROUP DENTAL / VISION APPLICATION

Argus Dental & Vision, Inc.

Group No. ____________

SIC No._______________

Legal Name of Group_______________________________________________________ Phone (_______)___________________

Physical Address ______________________________________________________

Fax (_______)_____________________

City\State\Zip_________________________________________________________ EMAIL ADDRESS_____________________

Billing Address (If different)___________________________________________________ Phone (_______)________________

City\State\Zip_________________________________________________________

Fax (_______)_____________________

Contact for Administration & Eligibility ___________________________ Contact for Billing ____________________________

# Employees: ______ # Eligible ______ # of Employees with Dependents ______

Group Effective Date: _____ /_____ / ______

Policyholder Contribution:

Dental: $_______ per month _______ % of premium

Payroll Frequency:________

Vision: $_______ per month _______ % of premium

A check for the first month’s premium and other applicable fees must be attached to begin processing. Eligibility data will be submitted



using:

National Guardian enrollment forms



Email or electronic media (Employer must keep signed enrollment forms on file for future reference.)

Plan Selection: We elect to offer the following coverage’s to our Employees:



Dental Insurance:

Vision Insurance:

 Policy Year Calendar Year

Series_____________

Frequency: 12/12/12/12 12/12/24/12

Deductible:______ Annual Maximum: ____

Co-Pay: Class 1___ Class 2 ___ Class 3 ___

Orthodontia: Yes  No Maximum________]

Eligibility:

Permanent, full-time employees working _____ hours per week are eligible for coverage (Standard: 30 hours).

An eligible employee must have been actively at work on a full-time basis for _________ months in order to be eligible for coverage.

An eligible dependent must be less than ____ yrs. Old or less than _____ yrs. Old if a full-time student.

Participation: Depending on group size and coverage elected, specific participation requirements may apply. Participation must be met

before the insurance can be effective and must be maintained continuously while insurance is in force to prevent cancellation of

coverage.

I understand and agree that audits will be made by National Guardian Life Insurance Company now and in the future to verify the

number and names of [full-time employees] [members] of this group. I will furnish with application, and upon any future request, [a

current census and State Quarterly Unemployment Tax Report, and] any other information requested.

NVI/NDN GRP APP 04/06 FL

20060807

See reverse side

Group Dental / Vision Application

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