Form Ecf-Vt-D - Dental Enrollment / Change Form - Northeast Delta Dental

800-537-1715 Corporate • 603-223-1230 Eligibility • 603-223-1252 Eligibility Fax

Please send form to:

Northeast Delta Dental

Delta Dental Plan of Vermont

PO Box 2002

DENTAL ENROLLMENT / CHANGE FORM

Concord, NH 03302-2002

Web site:

PLEASE TYPE OR PRINT LEGIBLY – IN BLUE OR BLACK INK ONLY

1. SUBSCRIBER INFORMATION - To be completed by Employee

LAST NAME (SUBSCRIBER)

FIRST NAME

SOCIAL SECURITY / I.D. #

GENDER

DATE OF BIRTH (MM-DD-YYYY)

M

F

MAILING ADDRESS

CITY

STATE

ZIP

TELEPHONE NO.

(

)

E-MAIL

MARITAL STATUS

SINGLE

MARRIED / CIVIL UNION PARTNER

DIVORCED

WIDOWED

OTHER

2. GROUP INFORMATION

GROUP NAME

STREET ADDRESS, CITY, STATE, ZIP

GROUP NUMBER

SUBLOCATION NUMBER

DIVISION

MISC. INFO (i.e. STORE LOC)

EFFECTIVE DATE (MM-DD-YYYY)

EMPLOYEE DATE OF HIRE (MM-DD-YYYY)

EMPLOYEE DATE OF REHIRE (MM-DD-YYYY)

3. REASON FOR ENROLLMENT/CHANGE:

(MM-DD-YYYY)

EXACT DATE OF STATUS CHANGE

MISCELLANEOUS CHANGE:

 Name change – Previous name:

ADD:

DELETE:

 Transfer from sublocation:

 New enrollment

 Annual open enrollment

 Address change

 Annual open enrollment

 Employment change for spouse/civil union

 Other:

 COBRA Due to:

partner

 Marriage/Civil union

 Full-time to part-time employement status

 Birth

 Other:

 Divorce/Termination of a civil union

COVERAGE LEVEL REQUESTED

 Adoption*

 Deceased

 Employee Only  Employee & Spouse/Civil union partner  Employee & Child

 Employment change for spouse/civil

 No longer dependent for IRS purposes

 Employee & Children  Family

union partner

 Retirement

 Part-time to full-time employment status

 Other

4. DEPENDENT INFORMATION - List all dependents to be newly enrolled, or those dependents who are affected by an addition or deletion listed

above in section #3. If you are enrolling some but not all of your eligible dependents, your other dependents must have coverage elsewhere.

Check if

Check if

Last Name

Relationship

Date Of Birth

Dependent

Dependent is

(If Different)

First Name

M.I.

To Subscriber

Mo Day Yr

under age 26

Incapacitated

1

Legal documentation may be required.

1

5. OTHER GROUP COVERAGE (COORDINATION OF BENEFITS)

Will you, your spouse/civil union partner, or any dependent be covered under any other group plan while this policy is in effect?

Yes

No

Will this dental coverage replace another Northeast Delta Dental Plan?

Yes

No

If yes to either question, complete the following:

DENTAL INSURANCE COMPANY

POLICYHOLDER ID # / SOCIAL SECURITY #

EFFECTIVE DATE (MM-DD-YYYY)

Statements made in this document are deemed to be representations and not warranties. I represent that all information is true and correct to the best of my knowledge. I

understand that by not choosing a network provider for myself or any family member, I may be responsible for higher out-of-pocket expenses. I also understand that the effective date

and termination date of my membership will be determined by my employer or plan sponsor in accordance with the underwriting guidelines of Northeast Delta Dental. If my employer or

plan sponsor requires employee contributions for this coverage, I authorize the deductions of these amounts from my wages. I further authorize my employer or plan sponsor to deduct

any premium which is owed by me as of the date my application is approved. I understand that my dependents and I must remain enrolled and can discontinue our coverage only during

open enrollment, except in the event of a qualified family status change. By signing below I hereby accept coverage.

This policiy provides dental benefits only. Review your policy carefully.

SIGNATURE (REQUIRED):

DATE:

Please retain a copy for your records

Form No. ECF-VT-D 08/10