Form 58792 - Dental/vision Insurance Application Or Change
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258792
DENTAL/VISION INSURANCE APPLICATION OR CHANGE
NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM
SFN 58792 (Rev. 10-2012)
NDPERS • PO Box 1657 • Bismarck • North Dakota 58502-1657
(701) 328-3900 • 1-800-803-7377 • Fax 701-328-3920
PART A
MEMBER IDENTIFICATION
Employee Name (Last, First, Middle)
NDPERS Member ID
Last Four Digits of Social Security Number
Date of Birth
Daytime Telephone Number
Organization Name
NDPERS Organization ID
Date of Hire
Active in the Military?
No
Yes
PART B
INSURANCE ELECTION
Effective Date of Change (MM-DD-YYYY):
Section 1
Reason for Change:
New Coverage (I do not have existing coverage)
Loss of Other Coverage
Annual Enrollment
Transfer Employment:
Cancel Dental Coverage
from _____________________ to ______________________
Cancel Vision Coverage
Transfer from existing policy (Complete Part D)
Remove Dependent
Add Dependent: Is this an adult child?
No
Yes, Please answer the following questions.
Is adult child married?
No
Yes
Is adult child Disabled?
No
Yes
Section 2
Level Of Coverage for Plan(s):
Dental Insurance
Vision Insurance
Single Coverage
Single Coverage
Employee and Spouse
Employee and Spouse
Employee and Child(ren)
Employee and Child(ren)
Employee and Family
Employee and Family
PART C
DEPENDENT INFORMATION
List all family members to be covered under the plan indicated in Part B, Section 2, other than yourself.
1.
Indicate dependent’s address below name if address is different from yours.
a.
For Relationship to you, enter one of the following: Spouse, child, stepchild, adopted child, legal guardian, or
b.
grandchild.
For Marital Status, enter one of the following: (S) Single, (M) Married, (D) Divorced, or (W) Widowed
c.
If your marital status is single and you are applying for family coverage, you are required to attach a copy of the state
2.
birth certificate for each Eligible Dependent unless previously submitted.
In compliance with the Federal Privacy Act of 1974, the disclosure of the individual's social security number on this form is
mandatory pursuant to 26 U.S.C. Section 3402. The individual's social security number will be used for tax reporting and as
an identification number.
Dependent Name (last, first, middle)
Relationship
Gender
Date
Social Security
Marital
Court
Active
If address is different then subscriber,
of Birth
Number
Status
Ordered
Military
indicate address under name
Coverage
No
Spouse
N/A
Yes
No
No
Yes
Yes
No
No
Yes
Yes
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