UCCI Dental Insurance Enrollment v2.1

United Concordia Dental Insurance Enrollment

from the Benefits Resource Center
For members & families of:
For members & families of

:
{associationName} members can use this form for new enrollments for United Concordia Flex Dental Insurance. Coverage will begin on the 1st day of the month following approval of your enrollment.

Begin by clicking the button below.

Your Information

Please complete all fields.
Name*

First NameMiddle InitialLast Name
Email*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState
Zip Code
Zip Code
Date of Birth*

MonthDayYear
Gender*
Social Security Number*

Partner Information

To add your spouse or domestic partner, please complete all fields.
Would you like to include your spouse or domestic partner?*

YesNo
Partner Name

First NameMiddle InitialLast Name
Partner Date of Birth

MonthDayYear
Partner Gender
Partner Social Security Number

Other Dental Coverage

If you or your dependents have other dental coverage, please complete the following fields.
Do you or your dependent(s) have other Group Dental Coverage?*

YesNo
Policyholder Name

First NameMiddle InitialLast Name
Insurance Company
Policy or Identification Number
Policy Effective Date

MonthDayYear
Date

PRICING AND OTHER DATA
Premium Type
1: Member, 2: Member/Spouse, 3: Member/Children, 4: Family
Premium Name
Member, Member & Spouse, Member & Child(ren), Family
Premium Amount
The premium price according to amount.
Service Fee
Monthly Amount

Availability & Provisions

Please review the following.
PROGRAM AVAILABILITY

Products are not available in any state where prohibited by law or where United Concordia does not have regulatory approval.

Domestic partner coverage is not permitted in Idaho.

STATE MANDATED PROVISIONS

CA: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

FL: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

AZ, GA, KY, NE, NH: All statements made by a Policyholder or by any Insured Member shall be deemed representations and not warranties, and no statements made for the purpose of effecting coverage shall void such coverage or reduce benefits unless contained in writing and signed by the Policyholder.

KS: Any person who knowingly and with intent to defraud, as stated on this Application, may be committing a fraudulent insurance act which may be a crime.

LA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NJ: All statements made by applicant are true and complete to the best of the applicant’s knowledge and belief. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NY: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

OR: Any person who knowingly and with intent to defraud, as stated on this Application, may be committing a fraudulent insurance act which may be a crime.

OR: Contestability is limited to two years as stated in the Group Policy.

TN: Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the Rules of (the American Arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award may include attorney’s fees if allowed by state law and may be entered as a judgement in any court of proper jurisdiction.

UT: Any matter in dispute between you and the company may be subject to arbitration as an alternative to court action pursuant to the Rules of (the American Arbitration Association or other recognized arbitrator), a copy of which is available on request from the company. Any decision reached by arbitration shall be binding upon both you and the company. The arbitration award may include attorney’s fees if allowed by state law and may be entered as a judgement in any court of proper jurisdiction.
Accept Availability & Provisions*

I have read & understand the Program Availability & State Mandated Provisions Statements.

Signature & Authorization

Please review the following statements and provide your electronic signature.
AUTHORIZATION STATEMENT*

I represent that all information supplied in this application is true and correct. Any person who knowingly, and with intent to defraud any insurancecompany or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading,information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
ELECTRONIC SIGNATURE

I understand that my electronic signature below is the legal equivalent of my manual signature and applies to my application for insurance coverage including the Statement of the Insured and Payment Authorization.

I herewith apply for dental insurance as stipulated above.
Electronic Signature*
Your Electronic Signature must match your Name entered previously.
Today's Date

MonthDayYear
Today's Date

Review & Pay

Please review your order and set up your recurring payment.

YOUR ORDER SUMMARY

Coverage Plan:	{premiumName}
Name:	{name}
Email:	{email}
Phone:	{phoneNumber}
*Monthly Premium Payment:**	${monthlyAmount}

If this information is not correct, please use the back button to return to the first section and complete the form. If the payment amount above does not correspond to the payment amount below, please contact us.

*Your Monthly Payment is the sum of the ${premiumAmount} Premium plus a ${serviceFee} Service Fee.

PAY BY CREDIT CARD

United Concordia Dental Insurance Premium

USD for each month

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

United Concordia Dental Insurance Enrollment

Your Information

Partner Information

Dependent Children Information

Other Dental Coverage

Availability & Provisions

PROGRAM AVAILABILITY

STATE MANDATED PROVISIONS

Signature & Authorization

ELECTRONIC SIGNATURE

Review & Pay