Enrollment/change Form - Delta Dental Of Idaho
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1Enrollment/Change Form
DELTA DENTAL OF IDAHO
P.O. Box 2870; Boise, Idaho 83701
(208) 489-3582
Enrollment Form:
Change Form:
Complete Sections I-III
Complete Sections I-V
I . E M P L O Y E E I N F O R M A T I O N
(
Please Print)
Name
Subscriber Number
Date of Birth
(First)
(Middle)
(Last)
(mo/day/yr)
Male
Female
Mailing Address
City, State, Zip
(Street or Route)
Telephone Number
Date Employed Full-time
No. Hours Worked/Week
Marital Status
Single
Divorced
Married
Widowed
yes
no
E-mail Address
Do you want to obtain your EOB electronically?
• Delta Dental of Idaho does not sell, share, rent, or lease personal information to third parties
.
Type of Coverage:
Employee
Employee + Spouse
Employee + One (1) Child
Employee + Two (2) or More Children
Employee + Spouse + One (1) Child
Employee + Spouse + Two (2) or More Children
Name of Employer
For
Group Number
Effective Date
Employer
Use
I I . D E P E N D E N T I N F O R M A T I O N
(List all family members you wish to enroll.)
Relationship to Applicant
Dependent’s Name
Date of Birth
Member Number
(First, MI, Last)
(mo/day/yr)
Add
Male
Spouse
Child
/
/
Stepchild
Other
Remove
Female
Relationship to Applicant
Dependent’s Name
Date of Birth
Member Number
(First, MI, Last
(mo/day/yr)
Add
Male
Spouse
Child
/
/
Stepchild
Other)
Remove
Female
Relationship to Applicant
Dependent’s Name
Date of Birth
Member Number
(First, MI, Last)
(mo/day/yr)
Add
Male
Spouse
Child
/
/
Stepchild
Other
Remove
Female
Relationship to Applicant
Dependent’s Name
(First, MI, Last)
Date of Birth
(mo/day/yr)
Member Number
Add
Male
Spouse
Child
/
/
Stepchild
Other
Remove
Female
Relationship to Applicant
Dependent’s Name
(First, MI, Last)
Date of Birth
(mo/day/yr)
Member Number
Add
Male
Spouse
Child
/
/
Stepchild
Other
Remove
Female
I I I . O T H E R D E N T A L C O V E R A G E
( M e d i c a l c o v e r a g e i n f o r m a t i o n i s n o t r e q u i r e d )
Do you or your dependents have dental coverage under another benefit plan?
Yes
No
If yes, complete this section
Name of Covered Person
Name of Covered Person’s Place of Employment
Relationship to You
Date of Birth (mo/day/yr)
Name of Dental Carrier
Dental Carrier’s Address
Covered Person’s Group No.
Covered Person’s Subscriber Number
________________________________
_________________________________
Are you and all dependents
If no, list
listed above on the plan?
covered
________________________________
_________________________________
dependents.
Yes
No
________________________________
_________________________________
I V .
C H A N G E R E Q U E S T S
Change current enrollment due to:
Loss of previous coverage
Marriage
Divorce
Birth
Death
Date event occurred _________________________ (
Other _____________________________________________________________________________________________
mo/day/yr)
Change my address to:
Change my name from:
To:
I hereby apply for the group coverage for which I may be eligible, and I authorize the release of my records to Delta Dental of Idaho. I understand completion of
this form does not guarantee eligibility and coverage will commence when all necessary documentation has been approved.
Employee Signature:
Date:
I:\Corporate Communications\Forms\Delta Premier, Producer brochures\Business Forms\Enrollment Form 406.doc
DDI-ENROLL 406
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