Please send form to:
Northeast Delta Dental
PO Box 2002
Concord, NH 03302-2002
Web site: www.nedelta.com
1. SUBSCRIBER INFORMATION - To be completed by Employee
LAST NAME (SUBSCRIBER) FIRST NAME SOCIAL SECURITY / I.D. # SEX
M F
DATE OF BIRTH
(MM-DD-YYYY)
MAILING ADDRESS CITY STATE ZIP TELEPHONE NO.
( )
MARITAL STATUS SINGLE MARRIED / CIVIL UNION PARTNER
DIVORCED WIDOWED
OTHER
E-MAIL
2. GROUP INFORMATION
GROUP NAME STREET ADDRESS, CITY, STATE, ZIP
GROUP NUMBER SUBLOCATION NUMBER DIVISION MISC. INFO (i.e. STORE LOC)
EFFECTIVE DATE (MM-DD-YYYY)
EMPLOYEE DATE OF HIRE (MM-DD-YYYY) EMPLOYEE DATE OF REHIRE (MM-DD-YYYY)
3. REASON FOR ENROLLMENT/CHANGE:
(MM-DD-YYYY)
EXACT DATE OF STATUS CHANGE
MISCELLANEOUS CHANGE:
Name change – Previous name:
Transfer from sublocation:
Address change
Other:
COVERAGE LEVEL REQUESTED
Employee Only Employee & Spouse/Civil union partner Employee & Child
Employee & Children Family
ADD:
New enrollment
Annual open enrollment
COBRA Due to:
Marriage/Civil union
Birth Other:
Adoption
Employment change for spouse/civil
union partner
Part-time to full-time employment status
DELETE:
Annual open enrollment
Employment change for spouse/civil union
partner
Full-time to part-time employment status
Divorce/Termination of a civil union
Deceased
No longer dependent for IRS purposes
Retirement
Other
800-537-1715 Corporate • 603-223-1230 Eligibility • 603-223-1252 Eligibility Fax
Delta Dental Plan of Vermont, Inc.
DENTAL ENROLLMENT / CHANGE FORM
PLEASE TYPE OR PRINT LEGIBLY – IN BLUE OR BLACK INK ONLY
Please retain a copy for your records
4. DEPENDENT INFORMATION - List all dependents to be newly enrolled, or those dependents who are affected by an addition or deletion listed
above in section #3. If you are enrolling some but not all of your eligible dependents, your other dependents must have coverage elsewhere.
Last Name
(If Different) First Name M.I.
Relationship
To Subscriber
Date Of Birth
Mo Day Yr
Check if
Dependent
under age 26 *
E-Mail for Spouse and/or
Dependents Over the Age of 14
*Check if dependent is incapacitated. Legal documentation may be required.
5. OTHER GROUP COVERAGE (COORDINATION OF BENEFITS)
Will you, your spouse/civil union partner, or any dependent be covered under any other group plan while this policy is in effect? Yes No
Will this dental coverage replace another Northeast Delta Dental Plan? Yes No If yes to either question, complete the following:
DENTAL INSURANCE COMPANY POLICYHOLDER ID # / SOCIAL SECURITY # EFFECTIVE DATE (MM-DD-YYYY)
Statements made in this document are deemed to be representations and not warranties. I represent that all information is true and correct to the best of my knowledge.
I understand that by not choosing a network provider for myself or any family member, I may be responsible for higher out-of-pocket expenses. I also understand that the
effective date and termination date of my membership will be determined by my employer or plan sponsor in accordance with the underwriting guidelines of Northeast Delta
Dental. If my employer or plan sponsor requires employee contributions for this coverage, I authorize the deductions of these amounts from my wages. I further authorize
my employer or plan sponsor to deduct any premium which is owed by me as of the date my application is approved. I understand that my dependents and I must remain
enrolled and can discontinue our coverage only during open enrollment, except in the event of a qualied family status change. By signing below I hereby accept coverage.
This policy provides dental benets only. Review your policy carefully.
SIGNATURE (REQUIRED):
DATE:
Form No. ECF-VT-D Rev. 10 0711
Marlboro College
PO Box A, Marlboro, VT 05344
70121
1000
0000
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signature
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