HomeMy WebLinkAboutDelta Vision enrollment form Social Security No. Group Number Effective Date /_ /_
New Applicant Change of Coverage
Late Enrollee Name/Address Change
Department Number Employee Number
SECTION I
Name (First, Middle Initial, Last) Telephone
( )
Date of Birth
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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 and/or vision care policies 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 and/or vision care policies 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 and/or vision care coverage for which I have applied. If any law or regulation requires additional authorization for release of dental and/or vision 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 employer or
group sponsor Financial Agreement to provide dental and/or vision 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.
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