Enrollment/change Form - Delta Dental Of South Dakota
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1Enrollment/Change Form
Effective date: ______________________
Delta Dental of South Dakota
PO Box 1157 Pierre, SD 57501
Hire date: __________________________
605-224-7345 Fax 605-224-0909
800-627-3961
Group Name: __________________________________
Group Number: ______________
Employee name: ____________________________________
SSN: ___________________
Mailing address: ____________________________________
DOB: __________________
City/State/Zip: _____________________________________
Sex:
_____M
_____F
Phone number: ___________________
Email address: ____________________________
Marital status
: Single ___ Married ___
(common law marriage is not recognized in South Dakota)
* List only the names of dependents you are enrolling:
First
Last (if different)
Sex
Birth date
Add
S
pouse
Drop
Add
Child
Drop
Add
Child
Drop
Add
Child
Drop
Add
Child
Drop
Add
Child
Drop
Please use an additional sheet if you have more dependents.
CHANGE in coverage
(Please list dependents you want removed from your plan in space provided above):
Marriage date: ________________________
Divorce date: ________________________
Other (explain): ___________________________________ Date of change: ___________
**Signature: ________________________________________ Date: ___________________
*I understand that should I decide to apply for single coverage, even though I am eligible for family coverage, I
cannot change my policy until open enrollment or a qualifying event (within the past 30 days). I also
understand that Delta Dental of South Dakota reserves the right to reject a change form.
**I accept the insurance provided by my employer’s group dental plan and authorize deductions from my
earnings for the required contributions, if any, toward the cost of the insurance. This authorization applies only
if employee contributions are required. I understand that by accepting insurance, I am required to remain
enrolled as a covered employee until the next open enrollment period, a qualifying event, or until the
termination of my employment.
6/16
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