DENTAL INSURANCE ENROLLMENT/CHANGE FORM CITY OF MILWAUKEE A SUBSCRIBER INFORMATION LAST NAME FIRST NAME M.I. GENDER DATE OF BIRTH MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED / / M F HOME ADDRESS CITY STATE ZIP CODE PHONE NUMBER SELECT A DENTAL INSURANCE PLAN COVERAGE TYPE 6 DIGIT EMPLOYEE ID (REQUIRED) CITY START DATE Delta PPO Delta EPO Careplus / / Single Family B REASON FOR SUBMITTING ENROLLMENT/CHANGE FORM (MUST SELECT ONE OPTION AND ENTER DATE) REQUIRED INITIAL ENROLLMENT OPEN ENROLLMENT RETURN TO WORK MARRIAGE DIVORCE NAME CHANGE From: To: Date of Change: / / If Retiree, Check Box: ADD/REMOVE SPOUSE/DEPENDENT DEATH OTHER C FAMILY COVERAGE -- LIST ALL INDIVIDUALS TO INCLUDE/ADD/REMOVE ON DENTAL INSURANCE PLAN LAST NAME FIRST NAME M.I. GENDER DATE OF BIRTH RELATIONSHIP Action Requested M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT D IF ENROLLING DEPENDENTS, SUBSCRIBER MUST COMPLETE THE FOLLOWING INFORMATION. Is any unmarried dependent child over the age of 26 on this form unable to be self-supporting due to a mental or physical handicap or disability? YES NO If Yes, please indicate name: ________________________________________________ SIGNATURE BLOCK (This application is not valid without being signed and dated.) E I apply for enrollment under the terms and conditions of the entity stated in Section A and subject to the coverage rules and conditions on the reverse side. I understand that coverage is not effective until I have satisfied the health plan coverage eligibility criteria and rules. I my employer’s Health Plan as administered by authorize any payroll/pension deductions that may be necessary to cover the cost of my plan. To the best of my knowledge, all statements and answers in this application are complete and true and that any misrepresentation of coverage in this application may result in loss or denial of coverage for me and my dependents. X / / SUBSCRIBER SIGNATURE DATE SIGNED FOR DER OFFICE USE ONLY GROUP NUMBER EFFECTIVE DATE / / Active Employees: Return completed form to DER Employee Benefits City Hall, Room 706 or Retirees: Return completed form to Retirement System Employes’
DENTAL INSURANCE ENROLLMENT/CHANGE FORM CITY OF MILWAUKEE A SUBSCRIBER INFORMATION LAST NAME FIRST NAME M.I. GENDER DATE OF BIRTH MARITAL STATUS M F / / SINGLE MARRIED DIVORCED WIDOWED HOME ADDRESS CITY STATE ZIP CODE PHONE NUMBER SELECT A DENTAL INSURANCE PLAN COVERAGE TYPE 6 DIGIT EMPLOYEE ID (REQUIRED) CITY START DATE Delta PPO Delta EPO Careplus Single Family / / B REASON FOR SUBMITTING ENROLLMENT/CHANGE FORM (MUST SELECT ONE OPTION AND ENTER DATE) INITIAL ENROLLMENT OPEN ENROLLMENT RETURN TO WORK REQUIRED MARRIAGE DIVORCE NAME CHANGE From: To: Date of Change: / / ADD/REMOVE SPOUSE/DEPENDENT DEATH OTHER If Retiree, Check Box: C FAMILY COVERAGE -- LIST ALL INDIVIDUALS TO INCLUDE/ADD/REMOVE ON DENTAL INSURANCE PLAN LAST NAME FIRST NAME M.I. GENDER DATE OF BIRTH RELATIONSHIP Action Requested M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT M F / / ADD DEPENDENT REMOVE DEPENDENT D IF ENROLLING DEPENDENTS, SUBSCRIBER MUST COMPLETE THE FOLLOWING INFORMATION. Is any unmarried dependent child over the age of 26 on this form unable to be self-supporting due to a mental or physical handicap or disability? YES NO If Yes, please indicate name: ________________________________________________ E SIGNATURE BLOCK (This application is not valid without being signed and dated.) I apply for enrollment under the terms and conditions of my employer’s Health Plan as administered by the entity stated in Section A and subject to the coverage rules and conditions on the reverse side. I understand that coverage is not effective until I have satisfied the health plan coverage eligibility criteria and rules. I authorize any payroll/pension deductions that may be necessary to cover the cost of my plan. To the best of my knowledge, all statements and answers in this application are complete and true and that any misrepresentation of coverage in this application may result in loss or denial of coverage for me and my dependents. X / / SUBSCRIBER SIGNATURE DATE SIGNED FOR DER OFFICE USE ONLY GROUP NUMBER EFFECTIVE DATE / / Active Employees: Return completed form to DER Employee Benefits City Hall, Room 706 or Retirees: Return completed form to Employes’ Retirement System
2019DentalEnrollmentFormFINAL.docx