Fillable Delta Dental Enrollment/change Of Status/waiver Form printable pdf download

ENROLLMENT/CHANGE OF STATUS/WAIVER FORM

PLEASE KEEP A COPY FOR YOUR FILES. Please note that completing this form does not guarantee coverage.

1. ALL GROUPS MUST COMPLETE THIS SECTION

Note: Incomplete forms will be returned.

Delta Dental Group Number _______________ Sublocation Number_____________

Salaried

Hourly

Effective Date _________________________ Date of Hire_____________________ OR Date of Rehire ___________

Non-Union

Union

Name of Employer ____________________________________________________ Location/Department _________

Other________________

Group Contact________________________________________ Phone __________________ Group Contact Email __________________________

2. EMPLOYEE / DEPENDENT / ADDITIONS / TERMINATIONS / CHANGES

Please check one of the options below:

Yes, I want to enroll in the dental and/or vision benefit plan(s) offered by Delta Dental of Illinois. (If enrolling in a dental benefit plan, please select a

network below.)

Delta Dental PPO/Delta Dental Premier

If applicable:

High Option

Low Option

DeltaCare (please complete the section below)

Dentist Name _________________________________________ Address ___________________________________ Facility Code _______

DeltaCare Dentist Change (please complete the section below)

Dentist Name _________________________________________ Address ___________________________________ Facility Code _______

DeltaVision

No, I do not want to enroll in the dental benefit plan.

(If you are declining, please write your name below and sign at the bottom of this form.)

No, I do not want to enroll in the vision benefit plan.

Social Security Number ______________________________ Employee’s Name ______________________________________________________

First Name

Last Name

Alternate ID # ______________________________________ # Hours Worked ________ Job Title________________________________________

Mailing Address __________________________________________________________________________________________________________

Street

City

State

Zip

Email Address __________________________________________________ Phone Number ____________________________________________

Marital Status:

Other

Date of Birth _____/_____/_____

Male

Female

3. REASON FOR SUBMITTING THIS FORM

Initial or Open Enrollment

COBRA

COBRA End Date ____/____/____

Retiree

k Rehire

k Loss of Other Coverage

k Other __________________________________________

Reinstatement due to:

Add Dependent (list below) due to:

k Birth

k Adoption

k Marriage

k Loss of Other Coverage

k Legal Guardianship

k Disabled Dependent

k Military Dependent

k Other ___________________________

Date of Qualifying Event ____/____/____

Drop Dependent (list below) due to:

k Age

k Death

k Divorce

k Other Coverage Elsewhere

Date of Qualifying Event ____/____/____

Termination of Employment

Date ____/____/____

Covered Under Spouse

Date ____/____/____

Name Change (Former Name ________________________________________________)

Address Change

4. PLEASE LIST ALL ELIGIBLE DEPENDENTS TO BE COVERED

ADD DELETE FIRST NAME

LAST NAME (if different)

BIRTH DATE (mm/dd/yyyy)

SEX (M or F)

1. Spouse:

2. Child:

5. DENTAL COVERAGE DESIRED

Employee Only

Employee & Spouse

Employee & Child(ren)

Entire Family

Is spouse covered under another dental plan?

Yes

Other Carrier Name _________________________________________________

Are dependents covered by spouse’s plan?

Yes

Spouse’s Carrier ____________________________________________________

Spouse’s Employer __________________________________________________

6. VISION COVERAGE DESIRED

Employee Only

Employee & Spouse

Employee & Child(ren)

Entire Family

I am requesting the coverage(s) I have selected above for which I am eligible under the contract issued by Delta Dental of Illinois for dental coverage and/or

by ProTec Insurance Company for vision coverage. I agree to continue membership in this program until the next open enrollment period. I certify that all the

information stated on this form is complete and true to the best of my knowledge and Delta Dental of Illinois/ProTec Insurance Company believing it to be true

shall rely and act upon it accordingly. I authorize my employer/group to deduct from my pay and remit any required contributions for the cost of the selected

coverage. This authorization is to remain in effect until Delta Dental of Illinois/ProTec Insurance Company is notified in writing to the contrary.

Signature of Applicant _________________________________________________________________________ Date _________________________

*Please Note: DeltaVision

is provided by ProTec Insurance Company, a wholly-owned subsidiary of Delta Dental of Illinois, in association with EyeMed Vision Care networks.

Mail to: Eligibility Department • P.O. Box 3384 • Lisle, IL 60532 • Fax (630) 369-0384 • Email

DEL7015764

EEAPP DENVIS

102013