Fillable Eligibility Enrollment/update Form - Delta Dental (Page 2 of 2) in pdf

Please read the following information carefully before completing the other side of this form. You should fill out this form if you are enroll-

ing for coverage or changing any information from an earlier enrollment. If you have any questions about filling out this form, your human

resources or personnel department can help you.

Subscriber Information

– This section must be completed for us to process your enrollment or update your records. All information

should apply to you, the primary subscriber. Please print clearly or type.

Effective Date:

The date that Delta Dental coverage takes effect for you and/or your dependents.

Status Definitions

(Please select only one status):

Active:

You are a current/active subscriber.

Retiree:

You are retired and your group continues to provide you with dental benefits.

COBRA:

You are no longer an active subscriber but you have continued self-paid coverage under COBRA. COBRA requires

many employers to offer extended self-paid coverage to certain employees and qualified beneficiaries who lose

group medical benefits coverage. Please check with your human resources or personnel department.

Surviving:

The surviving spouse or child of a deceased subscriber.

Plan Enrollment/Update Information

– This section should only be completed if you are: (1) Enrolling yourself or a family member

for the first time, or (2) if your benefits were terminated and are not being reinstated or, (3) if you are making changes to your

current enrollment information.

Enrollment:

Check for first time enrollment for yourself or your dependents.

Reinstatement:

Check for reinstatement coverage for yourself or your dependents.

Change/Corrections:

Check if any changes are being submitted on the form.

Termination of

Check only if you are terminating Delta Dental coverage for

Benefits:

yourself or a family member.

Group Transfers:

When transferring from one group to another, all dependents will transfer unless otherwise indicated.

This section should also be completed when transferring to COBRA.

When reporting a change or correction, the information that is incorrect or has changed should be listed on the line titled “from” and the correct

information should be listed on the line titled “to”.

When changing a rate code, please refer to the following explanation to select the code that describes who is being covered by your Delta

Dental program.

Rate Codes:

Rate 1

Employee Only

Rate 2

Employee and spouse

Rate 3

Employee, spouse and children

Rate 5

Employee, one child, no spouse

Rate 6

Employee and more than one child, no spouse

Enrollment/Corrections To Information

– This section should be completed when: (1) enrolling dependents or, (2) if you have

checked Changes/Corrections and are changing information that was previously submitted to Delta Dental. Please include both first and last

names of any individuals for whom you are enrolling or submitting a change or correction.

Dependent Status Definitions:

Legal:

Your current spouse

Surviving:

The surviving spouse or child of a deceased subscriber.

IRS Dependent:

An individual who is your dependent child according to the U.S. Internal Revenue Code. This could include

your unmarried dependent child who is attending a university, college, community college, junior college or

trade school on a full-time basis and for whom you provide principal support.

Disabled:

Your permanently disabled child.

Eligibility Enrollment/update Form - Delta Dental Page 2

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