Office of Pensions - Dental Application or Refusal

Dental Application or Refusal

This is the form that is required to be completed for the Dental Insurance or Refusal.
Effective Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal Information:

Please complete all of the Personal Information, this is required to complete the Dental Application.
Pension ID or SSN:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name:

First Name & Middle InitialLast Name
Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Dental Plan
Please select one Dental Plan:
*If you choose Dominion National DHMO, you MUST include a Dominion Dental
DHMO Dentist ID and the Dentist's Name, for yourself, spouse and all eligible
dependents.

Personal & Spouse Information
Personal Information

This has been pre-populated from the earlier information where possible.
Name:

First Name & Middle InitialLast Name
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN:
*Dominion Dentist ID:
*Dentist Name:
*If you choose Dominion National DHMO, you MUST include a Dominion Dental
DHMO Dentist ID and the Dentist's Name.
Spousal Information
Spouse Name:

First Name & Middle InitialLast Name
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
SSN:
*Dominion Dentist ID:
*Dentist Name:
*If you choose Dominion National DHMO, you MUST include a Dominion Dental
DHMO Dentist ID and the Dentist's Name.

By my signature below, I hereby certify the benefit election and statements made on this form are true and my choice. I have completed the required forms necessary to enroll in the dental election noted. I understand that by completing and signing the required forms, I am affirming that any dependents noted are eligible dependents as defined by the State's Eligibility and Enrollment Rules (found on the SBO website Section 2.0). I understand this is a binding election. Once enrolled, I may not drop or change coverage during the plan year unless I experience a qualifying event that warrants the change. During the next open enrollment period, I can drop or change my dental election.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Dependent Information