Dental Enrollment Form

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AMERICAN NATIONAL LIFE INSURANCE COMPANY OF TEXAS
ONE MOODY PLAZA, GALVESTON, TEXAS
DENTAL ENROLLMENT FORM
Administered By: Dentist Direct, LLC
75 South 500 West, Bountiful, UT 84010
EMPLOYER INFORMATION
EMPLOYER NAME
LOCATION
GROUP NO.
EMPLOYEE
LAST NAME
FIRST NAME
M.I.
STREET ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
BIRTH DATE
(
)
/
/
SEX
EMPLOYMENT DATE
MARITAL STATUS
OCCUPATION/TITLE
EMPLOYMENT STATUS
MALE FEMALE
MM
DD
YY
SINGLE
MARRIED
ACTIVE
INACTIVE
/
/
□
□
□
□
□
□
COVERAGE – Check Those That Apply
□
□
□
EMPLOYEE
SPOUSE
CHILDREN
REQUESTED EFFECTIVE DATE:____________
DEPENDENT INFORMATION
SPOUSE NAME
SEX
BIRTH DATE (MM-DD-YY)
/
/
□
□
MALE
FEMALE
CHILD NAME
SEX
BIRTH DATE (MM-DD-YY)
STUDENT (Over Age 19)
□
□
/
/
□
□
MALE
FEMALE
Yes
No
CHILD NAME
SEX
BIRTH DATE (MM-DD-YY)
STUDENT (Over Age 19)
/
/
□
□
□
□
MALE
FEMALE
Yes
No
CHILD NAME
SEX
BIRTH DATE (MM-DD-YY)
STUDENT (Over Age 19)
□
□
/
/
□
□
MALE
FEMALE
Yes
No
CHILD NAME
SEX
BIRTH DATE (MM-DD-YY)
STUDENT (Over Age 19)
/
/
□
□
□
□
MALE
FEMALE
Yes
No
WILL YOU OR ANY DEPENDENT HAVE OTHER DENTAL INSURANCE COVERAGE?_______________________
IF YES, PLEASE LIST THE NAME OF THE OTHER INSURANCE COMPANY AND PHONE NUMBER:
_____________________________________________________________________________________
REFUSAL/WAIVER – Complete Only If You Are Declining Coverage For Yourself Or Any Dependent
□
□
□
I DECLINE COVERAGE FOR:
MYSELF
MY SPOUSE
MY CHILDREN
REASON FOR REFUSAL:___________________________________________________________
ACKNOWLEDGMENT AND AUTHORIZATION
I hereby request coverage as outlined above under the American National Life Insurance Company of Texas group
dental plan offered by my employer.
I authorize my employer to deduct from my earnings, including any future
adjustments, any required contributions. I reserve the right to revoke or change this authorization by written notice. I
understand that if I have declined any coverage on myself or eligible dependent and wish to enroll at a later date,
coverage will be deferred in accordance with the plan provisions. I understand and acknowledge that information
concerning coverage, treatments, and services I may receive may be distributed and disclosed to my employer. I hereby
consent to the dissemination and disclosure of all information. I declare all answers true and complete.
WARNING: Any person who knowingly and with intent to defraud an insurer files an application or statement of claim
containing any false, incomplete or misleading information may be guilty of insurance fraud which is a crime.
DATE
CITY AND STATE
SIGNATURE OF EMPLOYEE
GDEN-ENR

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