REASON FOR SUBMITTING THIS FORM
NEW ENROLLEE REHIRE (Date: ___________________)
IF THIS IS FOR CHANGE, WHAT IS THE REASON?
BIRTH/ADOPTION (Name:______________________________) _______________
MARRIAGE/ DIVORCE _______________
ADD/ DROP DEPENDENT (Name: _____________________) _______________
TERMINATION OF BENEFITS (Reason: _____________________) _______________
LOSS OF DENTAL BENEFITS _______________
NAME CHANGE (Former Name: ___________________________) _______________
ADDRESS CHANGE _______________
GROUP TRANSFER (From ______________ to _______________) _______________
COBRA APPLICATION _______________
EMPLOYEE’S LAST NAME FIRST M.I. SSN OR EMPLOYER-ASSIGNED ID DATE MO DAY YR SEX
HOME ADDRESS - STREET CITY STATE ZIP
EMPLOYER NAME AND LOCATION (CITY & STATE) DATE MO DAY YR
LIST ALL ELIGIBLE FAMILY MEMBERS TO BE COVERED DATE OF BIRTH
LAST NAME FIRST M.I. MO DAY YR
ENROLLMENT/CHANGE/WAIVER FORM - Dental
WHAT TYPE OF COVERAGE ARE YOU APPLYING FOR?
EMPLOYEE ONLY EMPLOYEE & SPOUSE / DOMESTIC PARTNER
EMPLOYEE & ONE CHILD EMPLOYEE & CHILDREN ENTIRE FAMILY
YOUR MARITAL STATUS SINGLE MARRIED
IF YOU ARE NOT ACCEPTING COVERAGE FOR YOUR SPOUSE OR DEPENDENTS,
ARE THEY COVERED BY ANOTHER DENTAL PLAN? YES NO
EMPLOYER USE ONLY
GROUP NUMBER ______________ EMPLOYEE ID: _____________ EFFECTIVE DATE ___________________
SIGNATURE IS REQUIRED DATE
PLEASE NOTE THAT COMPLETING THIS FORM DOES NOT GUARANTEE COVERAGE.
COMPLETE THIS SECTION IF YOU ARE ACCEPTING, CHANGING OR TERMINATING COVERAGE
EMPLOYEE’S LAST NAME FIRST M.I. SSN OR EMPLOYER-ASSIGNED ID
PLEASE CHECK ONE:
I HAVE COVERAGE THROUGH MY SPOUSE
I HAVE OTHER DENTAL COVERAGE
I DO NOT HAVE OTHER DENTAL COVERAGE
Waive / Cancel Coverage
SIGNATURE IS REQUIRED DATE
Acceptance of Coverage
I accept the insurance provided by my employer’s group insurance plan. I
authorize deductions from my earnings for the required contributions toward
the cost of insurance. (This authorization applies only if employee contribu-
tions are required.) I understand that by accepting insurance, I am required to
remain enrolled as a covered employee and cannot make an elective change
in the coverage selected until the next open enrollment period, if there is one
provided for in the Master Agreement to Provide Dental Benefits.
Waiver of Coverage
I understand that if I decide not to apply for coverage, or if I apply only for
single coverage even though I am eligible for family coverage, any subse-
quent application will be subject to the applicable terms and conditions of
the Master Agreement to Provide Dental Benefits, which may require addi-
tional limitations and waiting periods. I also understand that Delta Dental of
Wisconsin, Inc. reserves the right to reject such an application.
EMPLOYER NAME AND LOCATION
COMPLETE THIS SECTION ONLY IF YOU ARE WAIVING COVERAGE
For “Rel Code,” use the following codes to describe the relationship of
dependents to you:
01=Spouse 24=Dependent of Your Minor Child
15=Legal Ward 38=Dependent of Domestic Partner
17=Stepchild 53=Domestic Partner
Indicate “Yes” or “No” if the dependent is married.
Indicate “Yes” or “No” if the dependent is disabled.
Indicate “Yes” or “No” if your domestic partner and/or dependent child is
considered a tax dependent under federal law. You do not need to complete
this box for your spouse. Note: There may be tax consequences to you when
you cover dependents (domestic partners and children) that are not depen-
dent on you for at least 50% of their support.
THIS APPLICATION IS NOT FOR HEALTH INSURANCE WITH DENTAL. THIS APPLICATION IS ONLY FOR THE SUPPLEMENTAL DENTAL PLAN.
Open Enrollment 2018
Return completed forms to Human Resources by October 27 deadline:
Fax: 608-263-5778 | Ask HR form in ServiceNow