CPS Guardian Dental Enrollment Form

GUARDIAN

The Guardian Life Insurance Company of America
Benefits Effective:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please check appropriate option
Please obtain this from your Employer

Class? Division? Subtotal Code?
Class
Division
Subtotal Code
About you
Name

First NameMiddle NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Are you married or do you have a spouse?
Do you have children or other dependents?
Date of marriage/union

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Placement date of adopted child:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
About Your Job
Hours worked per week
Job Title
Work Status
Date of full time hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
About Your Family

Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you,as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception. Dependencytax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents suchas a grandchild, a niece or a nephew.
Spouse (First, MI, Last Name)

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child/Dependent 1 (First, MI, Last Name)

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Add or Drop
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Status (check all that apply)
Child/Dependent 2 (First, MI, Last Name)

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Add or Drop
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Status (check all that apply)
Child/Dependent 3 (First, MI, Last Name)

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Add or Drop
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Status (check all that apply)
Child/Dependent 4 (First, MI, Last Name)

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Add or Drop
Gender
Social Security Number
Date of Birth (mm-dd-yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Status (check all that apply)
Drop Coverage
The date of withdrawal cannot be prior to the date this form is completedand signed. "Last Day of Coverage"

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Termination of Employment Retirement. "Last Day Worked"

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Event
Date of Event

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Coverage Being Dropped
Loss Of Other Coverage:I and/or my dependents were previously covered under another insuranceplan. Loss of coverage was due to:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I have been offered the above coverage(s) and wish to drop enrollment for the following reasons:
If Other (additional information may be required)
PPO - Dental Coverage: You must be enrolled to cover your dependents. Pick only one
I do not want this coverage. If you do not want this Dental Coverage, please mark all that apply
Signature
Should be Empty:

GUARDIAN

Please obtain this from your Employer

About you

About Your Job

About Your Family