Membership Enrollment Form printable pdf download

Delta Dental Individual and Family - Singular for AAA Members

Enrollment Application

Delta Dental of Minnesota

When completing this enrollment application, use an ink pen and print clearly. If information is missing or illegible, this form will be returned and it will

delay your enrollment. For information or assistance in completing this form, call Customer Service at 651-406-5959. Send completed application to:

Delta Dental of Minnesota

Attn: Enrollment Department

PO Box 330 Minneapolis MN 55440-0330.

PART A – SUBSCRIBER INFORMATION – Subscriber must be a AAA Minneapolis (Mpls) member.

Subscriber’s Name:

Social Security Number

Last

First

Middle Initial

Primary AAA Mpls Member

Gender:

Date of Birth

Day Phone Number

Evening Phone Number

Email Address

Male

Female

Address

Subscriber’s

Address:

City

State

Zip Code

Primary AAA Mpls Membership Number:

PART B – ENROLLMENT OPTIONS

Select One Plan Option

Plan 1 ($25 Deductible/$1000 Plan Maximum)

Plan 2 ($25 Deductible/$1500 Plan Maximum)

Select Who Is To Be Enrolled:

Your AAA and Singular membership categories must match.

Subscriber Only

Subscriber + One Dependent

Family (Three or more)

Complete this section if you selected the enrollment option of Subscriber+One or Family. If more than four family members are being enrolled, attach a

list of additional dependent information in the below format. Dependent children can only be enrolled up to age 23.

Relationship to Primary

First Name, Middle Initial, Last Name

Date of Birth

AAA Mpls Member

(Include Last Name Only if Different From Subscriber’s)

Gender

Month/Day/Year

Spouse/Domestic Partner

Dependent Child

PART C – PAYMENT OPTION INFORMATION – Select a payment option and billing frequency. Note: A $25 one-time enrollment fee

applies unless you choose the annual payment option.

A. Direct Withdrawal from Checking Account:

Monthly

Quarterly

Annual

Name on Checking Account: ____________________________________ Bank Name: _____________________________________

: ___________________________________

________________________

______

Routing Number

Checking Account Number:

The first premium including the enrollment fee (if applicable) will be charged immediately. Future premiums will be charged to your account on the 6th

business day of each coverage period.

Credit Card:

Quarterly

Annual

American Express

Discover

MasterCard

Visa®

Credit Card Number __________________________________________ Exp. Date _____/_____ Security Code ________

Name As It Appears On Credit Card___________________________________________________________________________

The first premium including the enrollment fee (if applicable) will be charged immediately. Future premiums will be charged to your account on the 6th

business day of each coverage period.

Check:

Quarterly

Annual

Send this form and your check payable to Delta Dental of Minnesota for the first quarter’s premium

plus the enrollment fee or the annual premium. Future premiums will be billed prior to the start of each coverage period.

PART D – AUTHORIZATION AND VERIFICATION – Sign and date application as verification of your enrollment.

I have read the information contained in the application and choose to enroll. I understand the benefits and restrictions of this plan as stated in the material

provided with the application. I certify the information contained in this application is true and complete. Any intentional omission or misrepresentation may

constitute insurance fraud which could result in possible criminal penalties and/or a claim for civil damages. I understand my enrollment is subject to receipt of

payment and verification of funds. The start and cancellation dates of my insurance coverage will be determined by Delta Dental of Minnesota. The start date is

generally the first day of the month following receipt of the enrollment application. If I have selected Payment Option A or B, I authorize Delta Dental to withdraw

funds from my checking account or debit my credit card. I understand that if funds/credit balances are not available or payment is not made timely I will no longer

be eligible for coverage. If I decide I do not want the contract, I may return it within 10 days after receipt with a written statement requesting termination of the

contract. Upon return, the contract will be deemed void, and any money paid will be refunded minus any claims that may have been paid. I understand that I

must enroll for one full year and if I terminate this contract or discontinue enrollment for any reason, I will not be able to re-enroll for a period of two years.

Subscriber Signature:

Date:

E55 AAA 04.25.2014

Membership Enrollment Form

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