Fillable Eligibility Enrollment/update Form - Delta Dental printable pdf download

Eligibility Enrollment/update Form - Delta Dental

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Eligibility Enrollment/Update

Check:

Indiana

Michigan

North Carolina

Ohio

–

Client Name: ____________________________________________

Client#/Subclient#

ABCDEF1 2 4

3 5 6

Subscriber Information

(please complete for all enrollments/updates:) Example:

Subscriber Name (Last)

(First)

(M.I.)

Sex

Status*

Active

COBRA

Male

Retiree

Surviving

Female

Subscriber Social Security Number

Birth Date

Coverage Effective Date

Hire Date

–

Street Address

Check here if this

is a new address

City

State

ZIP Code

–

Plan Enrollment/Update Information

(please indicate type of update and fill in appropriate information):

Type of Update:

New Enrollment

Reinstatement

Change/Correction to Information

Termination of Benefits

Waive Benefits

Group Transfer

Rate Code Change*

Change is for:

From: Client/Subclient#

To: Client/Subclient#

From:

To:

Effective Date of Change

Subscriber

Dependent

–

Enrollment/Corrections to Information

(please fill in for spouse/dependents for first-time enrollment or corrections):

SPOUSE Name (Last)

(First)

(M.I.)

Sex

Male

Female

Social Security Number

Birth Date

Status*

–

Legal

Surviving

DEPENDENT #1 Name (Last)

(First)

(M.I.)

Sex

Male

Female

Social Security Number

Birth Date

Status*

–

IRS Dep.

Surviving

Disabled

Sponsored

DEPENDENT #2 Name (Last)

(First)

(M.I.)

Sex

Male

Female

Social Security Number

Birth Date

Status*

–

IRS Dep.

Surviving

Disabled

Sponsored

DEPENDENT #3 Name (Last)

(First)

(M.I.)

Sex

Male

Female

Social Security Number

Birth Date

Status*

–

IRS Dep.

Surviving

Disabled

Sponsored

DEPENDENT #4 Name (Last)

(First)

(M.I.)

Sex

Male

Female

Social Security Number

Birth Date

Status*

–

IRS Dep.

Surviving

Disabled

Sponsored

*See reverse side for instructions and explanation of codes.

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false

or deceptive statement is guilty of insurance fraud.

_________________________________________

_________________________

Subscriber’s Signature

Date

314-55

(10-15)