Dental Sign Up

DELTA DENTAL
SMALL BUSINESS PROGRAM
ENROLLMENT/CHANGE FORM
Enrollment guidelines (except for PPO Vol): 1. Eligible employees electing coverage for themselves must enroll following completion of their eligibility period. Employees who do not enroll cannot enroll at a later time unless they show proof of loss of prior coverage under another dental program. 2. Enrollees electing dependent coverage must enroll all eligible dependents. Enrollees declining dependent coverage cannot enroll their dependents at a later time unless the dependents show proofoflossofprior coverage under another dental program.
CompanyGroup Name
Delta Dental PPOsmDeltaCare®USA
Requested Effective date*

MonthDayYear
Date
Enrollee name (Last name, First name)*
Social security number*
Gender

MaleFemale
Date of birth*

MonthDayYear
Date
Date of hire*

MonthDayYear
Date
Address*

Mailing address

Street Address Line 2

CityState

ZIP
Cell Phone #*
Dependents to be Enrolled or Deleted Spouse/domestic partner name (last, first)
Enrollee signature*

Clear
Date*

MonthDayYear
Date
This form must be received no later than the 25th of the month prior to the desired effective date. Please allow 5 days to process.

Vision coverage by EyeMed is underwritten by Fidelity Security Life Insurance Company, 3130 Broadway, Kansas City, MO 64111
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