HomeMy WebLinkAboutDelta Dental enrollment form
DD-211DD Revised 12-11
DENTAL ENROLLMENT / CHANGE APPLICATION
teamservice@deltadentalia.com
www.deltadentalia.com
Fax: 1-888-558-9212
Phone: 1-877-983-3582
Social Security Number
Group Number Effective Date
____/_____/_____
New Applicant Change of Coverage
Late Enrollee Name/Address Change
Part-time to Full-
time
Dept/EE Number
SECTION I
Name (First, Middle Initial, Last)
Telephone
( )
Date of Birth
____/____/___
Male
Female
Complete Address – Street City State Zip
Status Single Married
Other (specify)________
Hire Date
___/___/___
Employer Name & Location Please check the coverage you are applying for:
Employee Only Employee/Spouse
Employee/Child(ren) Employee/Spouse/Child(ren)
SECTION II ADDITIONAL ELIGIBLE MEMBERS ELECTING COVERAGE
List eligible members of your family to be covered
First Name Middle Initial Last (if different)
Social
Security
Number
Birthdate
Sex
Full-Time
College
Student
Disabled
Status
Other
Dental
Coverage
Spouse
___/___/__ M
F
Disabled?
Yes
No
Yes
Eligible Child
___/___/__ M
F
Yes No
School Name:
Disabled?
Yes
No
Yes
Eligible Child
___/___/__ M
F
Yes No
School Name:
Disabled?
Yes
No
Yes
Eligible Child
___/___/__ M
F
Yes No
School Name:
Disabled?
Yes
No
Yes
Eligible Child
___/___/__ M
F
Yes No
School Name:
Disabled?
Yes
No
Yes
Other Dental Coverage - If any person(s) on this application has dental insurance through another company where the employer pays
any portion of the cost or makes payroll deductions, please complete: Contract holder:______________________________
___________________________________________________________________________ ____/____/___ Single Family
Name of other dental carrier Policy Number Effective Date Contract type
SECTION III CHANGE OF COVERAGE
Please check events requiring Contract changes: Marriage Death Divorce Birth/Adoption Drop Spouse/Child(ren) COBRA Terminating Benefits
Other (explain) __________________________ Name of Affected Party ____________________ Date of Event __________
SECTION IV AGREEMENT and CERTIFICATION
I have read and understand the Agreement and Certification and/or Waiver of Coverage language on the back of this application and
acknowledge receipt of a fully completed copy of this application.
ACCEPTANCE OF COVERAGE
________________________________ ____/____/____
Employee Signature Date
WAIVER OF COVERAGE
I waive dental coverage for my dependents and myself.
(Please indicate reason)
I (We) have coverage under another dental plan.
I (We) do not wish to enroll
________________________________ ____/____/____
Employee Signature Date
DD-211DD Revised 12-11
AGREEMENT AND CERTIFICATION
I certify that I am legally authorized to apply for coverage for myself and for all other persons named in this application.
I understand that I am making application for the coverage sponsored by my employer or group sponsor offered by Delta
Dental of Iowa. I authorize my employer, as my agent to deduct from my pay or collect from me in advance the premium
therefore and remit such sums to Delta Dental of Iowa on my behalf. This authorization is to remain in effect until Delta
Dental of Iowa is notified by me or my employer or group sponsor to the contrary. I understand that coverage for the
dental care policy applied for will not start until after this application and the monies deducted from my pay for payment
of the premium or paid to my employer for such premium are received and accepted by Delta Dental of Iowa and an
effective date is established by Delta Dental of Iowa. I understand that written notice of rate changes will be furnished by
my employer or group sponsor as my agent.
I certify that after this application was completed, I carefully and fully read it, that the statements and answers set forth
are full, true, and correct, to the best of my knowledge and belief, and that no information required to be given, either
expressly or by implication, has been knowingly withheld. I understand that Delta Dental of Iowa will rely upon the
completeness and truthfulness of the information given and the statements made, and that if I have made any false
statements or misrepresentations, or have failed to disclose or have concealed any material fact, Delta Dental of Iowa will
be entitled to declare the dental care policy applied for void and refuse allowance of benefits to any person thereunder.
I authorize any health care provider to release medical records to Delta Dental of Iowa when reasonably related to the
dental care coverage for which I have applied. If any law or regulation requires additional authorization for release of
dental records, I will give this authorization.
WAIVER OF COVERAGE
I understand that if I decide not to apply for coverage, or if I apply only for single coverage even though I am eligible for
family coverage, any subsequent application will be subject to the applicable terms and conditions of the Master
Agreement to Provide Dental Benefits, which may require additional limitations and waiting periods. I also understand
that Delta Dental of Iowa, reserves the right to reject such an application.