National Guardian Life Insurance Company
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1
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4Application To
Dental Insurance
National Guardian Life Insurance Company
Application
Home Office: Two East Gilman Street, PO Box 1191, Madison, WI 53701
Administrative Office: AlwaysCare Benefits, Inc., PO Drawer 98100
Baton Rouge, LA 70898-9100
Toll Free Telephone No: 1-888-729-5433
To Be Completed by Applicant
Applicant’s Name: ______________________________________________________________ DOB: ______________ Sex: ______
Last
First
MI
Month/day/year
Applicant’s SSN: _____-_____-_____ Will dependent children be covered?
Yes
No
Spouse’s Name: ________________________________________________________________ DOB: ______________ Sex: ______
Last
First
MI
Month/day/year
Spouse’s SSN: _____-_____-_____
Address: ___________________________________________ City: ________________________ State: ________ Zip ___________
Street or Post Office Box
Apt. Number
Home Telephone Number: (_____) _____-______________
E-mail address: ____________________________________________
Name of Employer: ____________________________________________________________________________________________
To Be Completed by a National Guardian Life Insurance Company Representative
(Check Coverage Desired:)
Individual
One-Parent Family
Two-Parent Family
Individual & Spouse
(Check Region Desired:)
Region 1
Region 2
Region 3
Region 4
Region 5
(Check Plan Desired:)
Low Plan
Waiting Period Plan 1
Waiting Period Plan 2
Waiting Period Plan 3
(Check Optional Riders Desired:)
Orthodontic Expense Rider
Temporomandibular Joint Treatment Expense Rider
Billing Mode:
Monthly
Quarterly
Semiannual
Annual
Employee Number: ___________________ Department Number: ____________________ Agent Number: ____________________
Billable Premium: ____________________ Premium Collected: _____________________
To Be Completed on Each Dependent Child
Name - First, Last, MI
Date of Birth
Sex
SSN
Check if:
Male
Handicapped child
Female
Male
Handicapped child
Female
Male
Handicapped child
Female
Male
Handicapped child
Female
Male
Handicapped child
Female
Male
Handicapped child
Female
Male
Handicapped child
Female
Do You have any other dental insurance in force with another company? Y es
N o
If "Yes," Please list Company name and Benefits:
Is this insurance intended to replace any other insurance now in force? Y es
N o
If "Yes," Please list Company name and Coverage being replaced:
1
NDNIND2005 APP-MN
version 3.0
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