Enrollment Form - Benefit Strategies
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1MCO Health and Welfare Fund
DELTA DENTAL
D
/
V
E
F
&
D
/
V
E
F
&
E
N
T
A
L
I
S
I
O
N
N
R
O
L
L
M
E
N
T
O
R
M
E
N
T
A
L
I
S
I
O
N
N
R
O
L
L
M
E
N
T
O
R
M
P
D
A
P
D
A
A
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L
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D
U
C
T
I
O
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H
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I
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A
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A
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L
L
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D
U
C
T
I
O
N
U
T
H
O
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I
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A
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I
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N
Delta Dental Plan of Massachusetts
F
:
6
0
3
-
6
4
7
-
4
6
6
8
P
:
6
0
3
-
6
4
7
-
4
6
6
6
1
0
2
3
F
:
6
0
3
-
6
4
7
-
4
6
6
8
P
:
6
0
3
-
6
4
7
-
4
6
6
6
1
0
2
3
A
A
X
X
H
H
E
E
X
X
T
T
E
E
-
-
:
:
G
G
C
C
@
@
.
.
M
A
I
L
L
A
R
K
B
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N
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A
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M
M
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M
MCO H&W Fund Administrator Mailing Address:
Benefit Strategies, LLC, PO Box 3938, Manchester, NH 03105-3938
Employer (Check One)
Effective Date:
Date of Hire:
Telephone #:
Dental Plan
MCO
Group Name:
__Comm of MA
Delta Dental PPO
__Bristol County
H&W Fund
__Dukes County
Plus Premier
__Plymouth County
Social Security Number:
Last Name (Subscriber):
First Name:
DOB:
Sex:
Home Address:
City:
State:
Zip Code:
Dependent children are covered until to age of 26 (Regardless
List All Dependents Covered Under Your Plan:
of Student Status) to the end of the month they turn 26
Last Name
Sex
Check if dependent is over
First Name
Date of Birth
(if different from subscriber)
(M, F)
19 and a Full Time
Student
Subscriber
Spouse
Children
Reason For Submission (Check One)
New Enrollment:
Single Coverage
Name/Address Change : ________________________________________________
Family Coverage
Add Dependent(s) to Plan:
__________________________________
Name(s)/DOB(s)
Coverage Level Change:
Single to Family
Remove Dependent
_________________________________________
: Name
Family to Single
Transfer to COBRA Status
Terminate Coverage:
Date of Termination: ________________________
Vision Plan Selected:
EyeMed Vision Plan
Correctional Industries Voucher Plan
(Check One)
Please Read and Sign Below:
I hereby certify that all information is true and correct to the best of my knowledge. Also, I 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 Delta Dental Plan of Massachusetts.
I hereby authorize my Employer to deduct from my pay $3.00/week for Single Coverage or $6.00/week for Family Coverage as selected
above for my participation in the MCO Health and Welfare Fund’s Dental/Vision benefit plans.
Employee Signature:
Date:
Administrator Authorization:
Date:
Payroll Deduction: $
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