• GOVERNMENT OF GUAM

    GOVERNMENT OF GUAM

    Self Insured Dental Program Enrollment/ Change of Status E-Form

  • WELCOME TO NETCARE'S ONLINE ENROLLMENT PORTAL!

  • We have created this simple enrollment tool to assist you in either enrolling for group coverage or making changes to your current coverage. 

    Please be sure to fully complete and provide all the required information in order to process your enrollment application accurately and timely.  You can also preview your enrollment form prior to clicking the submit button to make any additional changes.

    Please follow the instructions carefully.

  • Please select which form you would like to submit*
  • Enrollment Type*
  • Please select which change you would like to make to your current policy
  • Please select which change you would like to make to your current policy.*
  • Date of Qualifying Event (QE)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Death*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Non-Payment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for Termination*
  • Date of Separation*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Retirement*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Other Termination Reason*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Employee Information

  • Employment Status*
  • Retirement Plan
  • Date of Employment
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*

  • Deduction Class

  • Please select your deduction class -*

  • Dependent Information

    Spouse/Domestic Partner & dependent children up to 26 years of age. Only fill out Address/Email Information for Dependent(s) opting to receive correspondence separately.

  • Please note: Subscribers that enroll/change status to include Spouse/Domestic partner must include Marriage Cert./Domestic Partner Affidavit along with Birth Certificates if dependents are added.  All supporting documents can be uploaded at the end of this page.

    • Spouse 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?
    • Child 1 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?
    • Child 2 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?
    • Child 3 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?

  • Additional Dependents

    • Dependent 1 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?
    • Dependent 2 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?
    • Would you like to add another dependent?
    • Dependent 3 
    • Are you adding or deleting this dependent?*
    • Date of Birth
       - -
      2 digit month, 2 digit day, 4 digit year
    • Will this dependent receive correspondence separately?

    • For any additional dependents, please submit another form after submitting this one.

    • Supporting Documents Upload 

    • If spouse has a different last name, please upload Marriage Certificate to continue.

    • Please upload Domestic Partner Affidavit to continue.

    • If child has a different last name, please upload birth certificate to continue.

    • Please upload legal guardianship papers as supporting documents.

    • For step child, please upload your Marriage Certificate and the child's Birth Certificate to continue.

    • For adopted child, please upload supporting documents as proof of adoption.

    • Browse Files
      Drag and drop files here
      Choose a file
      Cancelof

  • Other Coverage

    If you or your dependent(s) have dental coverage elsewhere, please complete the section below for coordination of benefits with your NetCare Plan. Otherwise, please press Next.
    • Other Coverage 1 
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Other Coverage 2 
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Other Coverage 3 
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Other Coverage 4 
    • Effective Date
       - -
      2 digit month, 2 digit day, 4 digit year

  • Acknowledgement and Agreement

  • I agree that I shall abide by the provisions of coverage in the policy under which I am enrolled.

    I have read and understand the eligibility requirements and attest that I and all dependents meet these requirements.

    I understand that it is my responsibility to report any changes in the eligibility of my dependents.

    I understand that newly eligible dependents, to include legal guardians, may only be added within 31 days from becoming eligible or during Open Enrollment period.

    I understand that NetCare Life & Health Insurance Co. (NetCare) has the
    right to request required documents at any time and failure to submit these documents may result in a loss of coverage or service at the discretion of NetCare Life & Health Insurance Co.

    Should this occur, I understand and agree I may be responsible for the cost of all health care provided to me and my dependents.

    I understand that the providing of coverage and service does not constitute acceptance of eligibility by NetCare Life & Health Insurance Co. until eligibility for coverage has been proven.

    I further agree that I will pay the premium, including my employer’s portion, for any periods where I am on Leave Without Pay (LWOP) directly to Department of Administration.

    I hereby authorize GovGuam to deduct the required cost for this program and acknowledge that I am responsible for ensuring the accuracy of these deductions.

    I understand that failure to make the necessary premium payments may result in
    termination of coverage without notice. Any unpaid premiums or claims will remain my responsibility, and I will not be eligible to re-enroll until all outstanding obligations have been fully satisfied. Once all obligations are cleared, re-enrollment will only be permitted during the Open Enrollment period.

    I acknowledge I further understand that any claims asserted by myself or
    my dependents against NetCare or any provider, whether based in tort, contract or otherwise (including professional liability) are subject to binding arbitration.

    Fraud Warning Notice: Any person who, with intent to defraud or knowing
    that he/she is facilitating a fraud against an insurer, submits a request for enrollment, or files a claim containing or false or depictive statement is guilty of insurance fraud.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year

  • Form Review

  • Please review your form before submitting. You can use the button below to preview your completed form. If there are any sections you wish to edit, you can go back and update your response.

    If you have verified that your form is complete and correct, please acknowledge the statement below and press the submit button.

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