Dental Change Form - Arkansas Blue Cross And Blue Shield Page 2
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46 OWNERSHIP CHANGE
From:
First Name________________________ M.I.______Last Name_______________________
To:
First Name________________________ M.I.______Last Name_______________________
7 SPLIT POLICY
Indicate the name of the covered person(s) you want covered on a separate policy with identical cover-
age.
Reason Code*
First Name
M.I.
Last Name
Suffix
Date of Change
Date of Birth
(see below)
i
*Reason Codes:
1-Divorce
2-Aging Off
3-Marriage
4-Other (spec
fy above)
Please provide address information for new policyholder ONLY:
Residential Address:
S treet ___________________________________________________________
City ____________________________________ State______ Zip ___________
Mailing Address:
Street ___________________________________________________________
City ____________________________________ State______ Zip ___________
Billing Address:
Street ___________________________________________________________
City ____________________________________ State______ Zip ___________
Please set up the billing mode for my new policy:
Monthly Bank Draft
Quarterly Invoice
Semi-Annual Invoice
Annual Invoice
(Must complete attached bank draft form)
8 CHANGE TYPE OF COVERAGE AND PLAN SELECTION
o Individual
o Individual and Spouse
o Individual and Child(ren)
o Individual/Spouse and Child(ren)
Please add the following dependent(s):
IMPORTANT NOTE:
Children age 26 and older must apply on their own.
M.I.
First Name
Social Security No.
Last Name
Suffix
Relationship
Sex
Date of Birth
o Yes o No
Do all dependents listed above live in Arkansas?
If "no," please provide: Name: _________________________ Address: ________________
Reason: ________________________________________________
o Yes o No Have any of the proposed insureds had any other dental coverage within the last 12 months?
If "yes," effective date: _____/_____/_______
Termination date: _____/_____/_______
Name of Company: _______________________ ID Number: _______________________
Page 2
Non-Under DentalChgFm (R01/12)
(Continued on page 3)
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