Form 3460 Ca Sbp - Enrollment/change Form

ENROLLMENT/CHANGE FORM - CA

FOR GROUP USE ONLY

Delta Dental of California

Group No.

Division

State

Small Business Program

Effective Date

Hire Date

Select a Plan:

PPO

DeltaCare® USA

1



OR



Delta Dental of California

Delta Dental of California

Name of Employer

VERY IMPORTANT - Please Print Legibly

Enrollee/Change Information

Change Dental Plan*

 Add/Term/Change Due to Qualifying Event





New Enrollment

Address Change



 Open Enrollment

SSN/Enrollee ID Number Correction or



PPO – Cancel

previous ID under which benefits are received

Enrollee Classification





Add/Delete Dependent

Terminate Enrollee Coverage



DeltaCare USA - Cancel





Marital Status Change

Change Dental Plans*







Full-Time

Hourly

Certified

*Enrollees can change plans only during open enrollment or due to a qualifying status change.







Retired

Salaried

Classified

Primary Enrollee Information



Other ___________________________

Gender

Social Security Number

Date of Birth

Marital Status

COBRA

 Male  Female

 Single  Married

(if applicable)

First Name

Last Name

Middle



Termination

Mailing Address (Street)

City

State

Zip



Reduction in Hours



Divorce/Legal Separation**

E-mail Address (internal use only)

Phone Number

Phone Type

 Cell

 Work

 Home



Widowed/Surviving Dependent**



Dependent Child No Longer Eligible**

Network Facility Name

Network Facility Number

Indicate qualifying date: ___________________

Policy Holder Name (first/last)

Date of Birth

Name of Other Dental Carrier

**If a dependent is enrolling under his/her social

Effective Date of Other Policy

Policy Holder Street Address

City

State

Zip

security number, the SSN currently enrolled

under must be provided.

Dependent Information

Relationship

Dependent First Name (Last only if different from enrollee)

Add / Term

Date of Birth

Male / Female

Disabled***

Network Facility Number‡

 

 



Spouse/Partner

 

 



Dependent

 

 



Dependent

 

 



Dependent

Please attach a separate sheet for additional dependent information. All dependents listed will be considered enrolled. ***Additional documentation, in the form of a doctor’s note, will be required for disabled

status. ‡Maximum of three facilities per family.



I authorize any payroll deduction that may be required towards the cost of this coverage. I certify that the above information is true and correct to the best of my knowledge.

I understand that changes can only be made during the annual open enrollment period unless I experience a qualifying family status change, in which case the change must be

consistent with that event, or as may otherwise be provided by the group contract.



I decline coverage at this time.

Signature of Enrollee ___________________________________________________________________________

Date __________________________________________________

DeltaCare USA is our closed network plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enrollees must select a primary care dentist in the DeltaCare USA network

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from whom they receive treatment.

Form 3460 CA SBP

#96082CA 2-16