Form 3460 Ca - Enrollment/change Form - Ca Dual Choice printable pdf download

ENROLLMENT/CHANGE FORM - CA

FOR GROUP USE ONLY

DUAL CHOICE

Group No.

Division

State

Delta Dental of California

Effective

Hire

Date

Select a Plan:

Fee-For-Service

DeltaCare

USA

Name of Employer

P.O. Box 429086

P.O. Box 1803

San Francisco, CA 94142-9086

Alpharetta, GA 30023

Benefit Package

Location

Pay Code

VERY IMPORTANT - Please Print Legibly

Enrollee/Change Information

Change Dental Plan*

Enrollee Classification

New Enrollment

Address Change

SSN/Enrollee ID Number Correction or

Full-Time

Hourly

Certified

Fee-For-Service - Cancel

previous ID under which benefits are received

Add/Delete Dependent

Terminate Enrollee Coverage

Part-Time

Salaried

Classified

DeltaCare USA - Cancel

Marital Status Change

Change Dental Plans*

Retired

Member/Other _______________

*Enrollees can change plans only during open enrollment or due to a qualifying status change unless allowed by the group contra ct.

Primary Enrollee Information

COBRA

(if applicable)

Social Security Number

Enrollee ID Number (if applicable)

Date of Birth

Gender

Marital Status

Termination

Male

Female

Single

Married

First Name

Last Name

Middle Initial

Reduction in Hours

Divorce/Legal Separation**

Mailing Address (Street)

City

State

Zip Code

Widowed/Surviving Dependent**

Phone Number

Phone Type

E-mail Address (internal use only)

(

)

Cell

Work

Home

Dependent Child No Longer Eligible**

Network Facility Name (DeltaCare USA only)

Network Facility Number (DeltaCare USA only)

Indicate qualifying date: _____________________

Name of Other Dental Carrier

Policy Holder Name (first/last)

Date of Birth

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

security number, the SSN currently enrolled

Effective Date

Policy Holder Street Address

City

State

Zip Code

under must be provided.

of Other Policy

Dependent Information

Dependent First Name

Name of School

Network Facility Number

‡

Add / Term

Social Security Number

Date of Birth

Male / Female

Student / Disabled***

Relationship

(last name only if different from enrollee)

(overage student)***

(DeltaCare USA only)

Spouse/Partner

Dependent

Please attach a sep arate sheet for additional dependent information. All dependents listed will be considered enrolled. ***Addi tional documentation will be required for disabled and student st atus.

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 if 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

1 DeltaCare USA is our prepaid plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enr

ollees must select a primary care dentist in the DeltaCare USA network from whom they receive

treatment.

Form 3460 CA

4-09