Enrollment/change /waiver Form
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1ENROLLMENT/CHANGE /WAIVER FORM
Group #_________
Employers Name: ________________________________
____________________________________________________________________________________________________________
PLEASE PRINT ALL REQUESTED INFORMATION
1. TO ENROLL (
)
Complete Section 1 and sign below
Employee’s Name: __________________________________________________________________________________
(Last, First, MI)
Date of Birth: ___________________________
Cobra – Termination Date ____________________________
(Mo/Day/Yr)
Residence State _______________________________ Zip ________________________________
Division _____________________________________
Occupation ___________________________________
Date of Full Time Hire __________________________
(Mo/Day Yr)
Male
Female
Social Security Number: _________-______-__________
Marital Status:
Single
Married
Widowed
Divorced
Myself
Spouse
Child(ren)
Electing Coverage for:
If Declining coverage for yourself or dependents, complete section 3 also.
DEPENDENT COVERAGE INFORMATION (List all Eligible Dependents to be added or deleted)
Print Full Legal Name (Last, First, MI)
Date of Birth (mo day yr)
ADD
DROP
RELATIONSHIP
1 _______________________________
______________
________________
2 _______________________________
______________
________________
3 _______________________________
______________
________________
__________________________________________________________________________________________________________
2. TO CHANGE NAME OR ADD/DROP DEPENDENT COVERAGE
(Complete Sections 1 & 2 and sign below)
New Name ____________________________ Old Name____________________________
If Due To Marriage, what is the DATE OF MARRIAGE? _________________________
If Due to Birth/Adoption of a child, what is the Date of Event? _____________________
If Due to Loss of Coverage, Date and Reason ___________________________________ (Proof Required)
Other, the Date of Event and Please Explain ____________________________________
Drop Dependent Coverage
Drop Coverage on:
Spouse
Child(ren) Give reason below
Due to Divorce – Date________________
Due to Death –Date___________________
Other Dental Coverage elsewhere
No longer student or over age
Due to Annual Election Period
_________________________________________________________________________________________________________
3. TO WAIVE COVERAGE
(Complete Section 3 and sign below)
Declining coverage for:
Myself
Spouse
Child(ren)
Important! If declining coverage on yourself or dependents please complete one of the reasons below and sign at the bottom:
I have been given the opportunity to apply for this dental coverage offered by my employer and have decided not to accept this
offer for myself or my dependents because:
I have coverage elsewhere. Provide name of insurance company: ________________________________
Other. Reason: __________________________________________________________________________
Should I desire to apply for coverage at a later date, I will be enrolled with limitations unless I can provide satisfactory proof of prior coverage
approved by the insurance carrier, the benefits will be issued standard.
If electing coverage provided by my employer, I authorize deductions from my earnings of the required contributions, if any, toward the cost of
this insurance. Authorization is only necessary if employee contributions are required.
PLEASE SIGN (EMPLOYEE SIGNATURE)
___________________________________________________
Print Name: ______________________________
Employee Signature
Date
05/2007
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