1. Enroll
DentalEye CareTo terminate all coverages

Employee Information

Marital Status: *As defined by state law or your Group.
SingleMarriedCivil Union*Domestic Partner*

Social Security Number:

Dept. Number:

Employee's Last Name, First Name, MI:

Date of Birth:

MaleFemale

Full Time Date of Hire:

Rehire

Occupation:

Hours Worked Each Week:

How are your earnings paid?
HourlySalaried

Street Address:

City:

State:

ZIP:

E-Mail Address:

Are you covered under another dental insurance plan?
Employee:
YesNo
Dependents:
YesNo

Are you covered under another eye care insurance plan?
Employee:
YesNo
Dependents:
YesNo

Dependent Coverage Information
List all eligible dependents to be added or deleted. (Employee must be enrolled to cover dependents)

How many dependents would you like to list?
012345

Please Sign (employee/policyholder) The certificate provides dental and eye care benefits only. Review your certificate carefully.
As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.

Employee Signature (Type your full name):

Date:

Policyholder Signature (Type your full name):

Date:

In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or mislead-ing information in an application for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefit, is guilty of a crime and may be subject to fines and criminal penalties, including imprisonment. In addition, insurance benefits may be denied if false information provided by an applicant is materially related to a claim. (State-specific statements on back.)

Employee Late Entrant Date:

Dependent Late Entrant Date:

Effective Date:

Class:

Dep. Code:

2. Change
Name Change

Add Dependent Coverage

Drop Dependent Coverage

3. Waiver
IF YOU DO NOT WANT COVERAGE, COMPLETE THE WAIVER SECTION. THE WAIVER MAY NOT BE ALLOWED FOR THIS PLAN, CHECK WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for:
Myself (does not apply to TRUST policies)
Spouse/Domestic Partner
Child(ren) Only
Spouse/Domestic Partner and Child(ren)
Because:

Name of Insurance Company and Employer of Dependent:

Should I desire to apply for this group insurance in the future, I realize that a “late entrant” penalty may be applied.