Enrollment/change/waiver Form - Delta Dental Of Wisconsin
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1Delta Dental of Wisconsin
Enrollment/Change/Waiver Form - Dental
PLEASE NOTE THAT COMPLETING THIS FORM DOES NOT GUARANTEE COVERAGE.
EMPLOYER USE ONLY
GROUP NUMBER
______________
______________
______________
______________
EFFECTIVE DATE
_________________________
COMPLETE THIS SECTION IF YOU ARE ACCEPTING, CHANGING, OR TERMINATING COVERAGE
EMPLOYEE LAST NAME
FIRST
M.I.
SSN OR EMPLOYER-ASSIGNED ID
DATE OF
SEX
BIRTH
MO
DAY
YR
F
M
HOME ADDRESS - STREET
CITY
STATE
ZIP
EMPLOYER NAME
EMPLOYER LOCATION
CITY
STATE
DATE OF
HIRE
MO
DAY
YR
LIST ALL ELIGIBLE FAMILY MEMBERS TO BE COVERED
RELATIONSHIP
DATE OF
BIRTH
SPOUSE LAST NAME (IF DIFFERENT)
FIRST
M.I.
SON
DAU.
MO
DAY
YR
REASON FOR SUBMITTING THIS FORM
COVERAGE TYPE
NEW ENROLLEE
REHIRE (Date: _____________________________)
WHAT TYPE OF COVERAGE ARE YOU APPLYING FOR?
Employee Only
Employee & Spouse
Date
IF THIS IS FOR CHANGE, WHAT IS THE REASON?
Occurred
Employee & Child(ren)
Entire Family
Birth/Adoption (Name:________________________________)
_______________
Marriage/ Divorce
_______________
YOUR MARITAL STATUS
Single
Married
Add/ Drop Dependent (Name: _____________________)
_______________
If you are not accepting coverage for your spouse or dependents,
Termination of Benefits (Reason: ______________________)
_______________
are they covered by another dental plan? Yes
No
Loss of Dental Benefits
_______________
Name Change (Former Name: __________________________)
_______________
ACCEPT COVERAGE
Address Change (_____________________________________)
_______________
Group Transfer (From _____________To _________________)
_______________
X
COBRA Application
_______________
Signature is Required
Date
COMPLETE THIS SECTION ONLY IF YOU ARE WAIVING COVERAGE
EMPLOYEE LAST NAME
FIRST
M.I.
SSN OR EMPLOYER-ASSIGNED ID
PLEASE CHECK ONE:
I have coverage through my spouse
I have other dental coverage
EMPLOYER NAME
EMPLOYER LOCATION
CITY
STATE
I do not have other dental coverage
WAIVE COVERAGE
X
Signature is Required
Date
Acceptance of Coverage
Waiver of Coverage
I accept the insurance provided by my employer’s group insurance plan. I authorize
I understand that if I decide not to apply for coverage, or if I apply only for single coverage
deductions from my earnings for the required contributions toward the cost of insurance.
even though I am eligible for family coverage, any subsequent application will be subject
(This authorization applies only if employee contributions are required.) I understand that
to the applicable terms and conditions of the Master Agreement to Provide Dental Benefits,
by accepting insurance, I am required to remain enrolled as a covered employee and cannot
which may require additional limitations and waiting periods. I also understand that Delta
make an elective change in the coverage selected until the next open enrollment period, if
Dental of Wisconsin, Inc. reserves the right to reject such an application.
there is one provided for in the Master Agreement to Provide Dental Benefits.
F708A-1411
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