Fillable Dental Plan Change Form For Employee printable pdf download

Dental Plan Change Form For Employee

Download a blank fillable Dental Plan Change Form For Employee in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Dental Plan Change Form For Employee with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Dental Plan Change Form

Employee Last Name

First Name

Social Security Number

Group Name

Section 1 – Change of Employee Information

Change Name:

Change Address to:

Employee Last Name

First Name

M.I.

Employee Home Address

From:

Employee Last Name

First Name

M.I.

City

State

Zip Code

To:

Section 2 – Change of Plan Option or Drop Coverage

Change of Plan Option

Drop all coverage for me and any covered dependents

Effective ____________________________

Change from Plan __________ to Plan

State reason:

__________

Section 3 – Add Dependent(s)

Dependent(s) are being added (check one):

As dependents acquired through birth, marriage,

Due to loss of eligibility under another health plan (name, group

As late enrollments

or legal adoption. (Attach copy of birth certificate,

number, and telephone number of the other plan must be written on

marriage license, or adoption papers.)

the back of this form, or attach copy of other plan’s ID card).

Dependent’s Last Name

First Name

M.I.

Sex

Relation

Birth Date

Social Security Number

(MM/DD/YY)

Section 4 – Drop Dependent(s)

Dependent(s) are being dropped (check one):

Because the person(s) listed below no longer meet the requirements

Due to becoming eligible under another health plan (name, group

for being an eligible dependent under the plan, because of age,

number, and telephone number of the other plan must be written on

marriage, or divorce (please explain reason on the back of this form).

the back of this form, or attach copy of other plan’s ID card).

Dependent’s Last Name

First Name

M.I.

Sex

Relation

Birth Date

Social Security Number

(MM/DD/YY)

Section 5 – Other Changes

Describe any other requested changes below:

Section 6 – Employee Signature

I hereby request coverage as outlined above under the group dental plan offered by my employer and

authorize my employer to deduct from my earnings, if applicable, including any future adjustments, and

any required contributions. I reserve the right to revoke or change this authorization any written notice

and understand that if I have declined any coverage on myself or an eligible dependent and wish to

enroll at a later date, coverage will be deferred in accordance with the plan provisions. I understand and

Employee Signature

acknowledge that information concerning coverage, treatments, and services I may receive may be

distributed and disclosed to my employer, and I hereby consent to the dissemination and disclosure of all

information. I declare all answers to be true and complete

Date signed

Office Use Only

Effective Date of Changes by Section #

Section 1

Section 3

Section 4

Section 5

Benefits Representative

Dental Plan Change Form For Employee

Related Articles

Related forms

Related Categories