GOVERNMENT OF GUAM ENROLLMENT FORM

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.

Employee Information
Employment Status*

Active EmploymentRetireeSurvivor of Retiree
Retirement Plan

DC Retirement PlanDB Retirement Plan
Please specify the agency you retired from
Full Name*

First NameM.I.Last Name
GovGuam Agency/Department*
Date of Employment

MonthDayYear
Date
Social Security No.*
Mailing Address*

Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone & Ext.
Please enter a valid phone number and extension if applicable.
Cell Phone/Other Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Sex
M = Male, F = Female, X = Other/Unspecified
Sex*

MaleFemaleUnspecified
Marital Status*
Email Address*
example@example.com

Deduction Class
Please select your deduction class -*

Class I - Employee, Retiree, or Survivor OnlyClass II - Employee, Retiree, or Survivor with Spouse/Domestic PartnerClass III - Employee, Retiree, or Survivor with Child(ren)Class IV - Employee, Retiree, or Survivor with Spouse/Domestic Partner with Child(ren)

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.
File Upload

Please upload any relevant supporting documents.
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
Full Name
Last Name, First Name & M.I.
Insurance Carrier Name
Relationship to Subscriber
Policy No.
Effective Date

MonthDayYear
Date

Other Coverage 2
Full Name
Last Name, First Name & M.I.
Insurance Carrier Name
Relationship to Subscriber
Policy No.
Effective Date

MonthDayYear
Date

Other Coverage 3
Full Name
Last Name, First Name & M.I.
Insurance Carrier Name
Relationship to Subscriber
Policy No.
Effective Date

MonthDayYear
Date

Other Coverage 4
Full Name
Last Name, First Name & M.I.
Insurance Carrier Name
Relationship to Subscriber
Policy No.
Effective Date

MonthDayYear
Date

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 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.
Signature*

Clear
Date Signed

MonthDayYear
Date

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.
I have reviewed my form and can confirm that I have completed it to the best of my knowledge. I understand that any further changes after submission would require a new form to be filled out.
Should be Empty:

GOVERNMENT OF GUAM

WELCOME TO NETCARE'S ONLINE ENROLLMENT PORTAL!

Employee Information

Deduction Class

Dependent Information

Delete Dependents

Other Coverage

Acknowledgement and Agreement

Form Review