Membership Enrollment Form - Delta Dental Of Minnesota
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1
2Delta Dental of Minnesota
Membership Enrollment Form
PART A – EMPLOYEE INFORMATION
– Employee
complete Parts A thru G and return form to benefit administrator.
Last
First
Middle Initial
Social Security Number
Employee’s
/
/
Name:
Male
Female
Single
Married
Widowed
Divorced
Legally Separated
Date of Birth (Month-Day-Year)
Gender:
Marital
/
/
Status:
Address
Day Phone Number
Evening Phone Number
Employee’s
City
State
Zip Code
Address:
PART B – ENROLLMENT INFORMATION
Complete If Your Employer Offers The
Select Coverage Type – Who Is Being Enrolled – Check One Box Only
Voluntary Orthodontic Program
If waiving coverage for employee and/or eligible family members, complete Part F.
*
Employee only*
Family
I Elect
I Do Not Elect
Employee and Spouse
No Coverage*
to Participate in the Voluntary Discount
Orthodontic Program
Employee and Dependent Child(ren)
PART C – DEPENDENT INFORMATION
Relationship
First Name, Middle Initial, Last Name
Date of Birth
Full Time
To Employee
(Include Last Name Only if Different From Employee’s)
Gender
Month/Day/Year
Student?
Unmarried?
Spouse
M
F
/
/
Dependent Child
M
F
/
/
Y
N
Y
N
Dependent Child
M
F
/
/
Y
N
Y
N
Dependent Child
M
F
/
/
Y
N
Y
N
Select a Plan Option:
Plan Option I - Delta Dental PPO
PART D – FOR MILLENNIUM CHOICE
GROUPS ONLY
SM
Plan Option II - Delta Dental Premier
PART E – FOR DeltaCare GROUPS ONLY
Clinic Code: ________________________________
Obtain Clinic Code from DeltaCare Provider Directory.
Please Note: Dental benefits are ONLY available when a clinic is chosen.
PART F – OTHER INSURANCE COVERAGE
–
Complete if employee and/or eligible dependents are not being enrolled.
Do you (the employee) have other dental coverage?
Yes
No Do your dependents have other dental coverage?
Yes
No
Name of Carrier: ___________________________________
Policy/Identification Number: ______________________________
I waive coverage for myself and/or my dependents and understand that by waiving coverage, whether entirely or partially paid by my
employer, that I waive the right to change this selection unless permitted in the group contract’s participation requirements and enrollment
restrictions. Delta Dental reserves the right to decline any further enrollment changes
.
Employee Signature:
Date:
PART G – EMPLOYEE SIGNATURE – Sign and date form as verification of your enrollment.
I am enrolling myself and/or my dependents and authorize payroll deductions, if applicable. Any person who knowingly and with intent
to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false
information or conceals for the purposes of misleafpding, information concerning any fact material thereto may commit a fraudulent act,
which is a crime and subjects such person to criminal and civil penalties.
Employee Signature:
Date:
PART H – GROUP ENROLLMENT INFORMATION - THIS PART TO BE COMPLETED BY EMPLOYER
New Group
Rehire Date Lay Off Began: ________/________/_______
Date Rehired: ________/________/_______
Hire Date: _______/________/________
Prior Coverage Start Date
: ________/________/________
(if applicable)
Return from Leave of Absence
Coverage Effective Date: ________/________/________
Date Leave Began:
________/________/________
Date Returned to Work: ________/________/________
Existing Delta Dental Group
Hire Date: _______/________/________
Employee Change Part Time to Full Time
Date of Status Change: ________ /________/________
Prior Coverage Start Date
: ________/________/________
(if applicable)
Effective Date:
________ /________/________
Coverage Effective Date: ________/________/________
New Hire –
Open Enrollment
Previously Waived Coverage or Loss of Coverage
Apply Probationary Period (if
applicable) to determine Effective Date
Effective Date:
Qualifying Event Reason:_________________________________
Hire Date: __________ /______/_______
______ /_______/_______
Hire Date: _____________ /_______/________
Effective Date:______ /_______/_______
Event Date: ___________ /_______/_________
Effective Date: ________ /_______/__________
---
Group Name:
Group & Subgroup Numbers:
(
)
Group Representative’s Signature:
Date:
Phone Number:
‹
Send Original Copy to Delta Dental
‹
Retain Copy For Your Records
‹
E01 05/12/09
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