3831
3831
Dental Enrollment Form
For New Enrollment, please complete ALL sections of this form. For Enrollment Changes, please select
the applicable “Type of Activity” in Section A and provide the identification number and employee
name in Section C (also complete Section D for dependent changes).
For best results, print in capital letters and avoid
contact with edge of box.
Example:
Fill in circles completely:  
Correct Incorrect
SECTION A: GENERAL INFORMATION
SECTION B: EMPLOYER USE ONLY
SECTION C: EMPLOYEE INFORMATION
—Please print clearly to expedite your request.
SECTION D: DEPENDENT INFORMATIONPlease list the added/cancelled dependents in this section. For more than six dependent
children, complete and attach an additional form. If dependent children listed in this section are disabled or full-time student age 19 or over, please
see your group administrator for a Dependent Certification Form, which should be completed and returned with the Dental Enrollment Form.
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1. TYPE OF PROGRAM
FFS—Indemnity, Active PPO, Passive PPO
(Please specify)
Concordia Access
Concordia Choice
Concordia Flex
Concordia Preferred
Concordia Select
Other_______________________
DHMO (Please specify)
Concordia Plus
Other_______________________
Provider Number (DHMO only)
2. TYPE OF ACTIVITY
New Enrollment
Cancel Coverage
Cancel All Coverage (Employee & All Dependents)
Cancel Dependent(s) Only
(List dependents to be cancelled in Section D)
Cancel Spouse Only
(List spouse to be cancelled in Section D)
Change (Include Group Number in Section B)
Add Dependent
(e.g., spouse, domestic partner, child, etc.)
Change Address
Reinstate Coverage
Change Group Number
Change Provider
Change Name
To COBRA Group
Other_________________________
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Original Employment Date (mm/dd/yyyy)
Effective Date (mm/dd/yyyy)
Spouse/Domestic Partner
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
Dependent
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
First Name M.I. Last Name
First Name M.I. Last Name
First Name M.I. Last Name
Home Address
City State ZIP Code
— 1 —
A B C
x
#1
#2
Employer Name
__________________________________________
Group Number (9 digits)
UCCI Payroll Location
5000 (05/10)
3831
3831
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Dependent
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
Dependent
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
Dependent
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
Dependent
Identification Number (Social Security Number) Date of Birth (mm/dd/yyyy)
Gender
Provider Number (DHMO only)
First Name M.I. Last Name
First Name M.I. Last Name
First Name M.I. Last Name
First Name M.I. Last Name
#3
#4
#5
#6
— 2 —
SECTION E: OTHER DENTAL COVERAGEDo you or your dependent(s) have other Group Dental Coverage? Yes No
If your answer is yes, please complete the following information.
I represent that all information supplied in this application is true and correct. Any person who knowingly, and with intent to defraud any insurance
company or other person, les an application for insurance containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Employee Signature Phone Number Email Address Date
Employer Signature Phone Number Date
Policyholder Name (First, M.I., Last) Insurance Company
Policy/Identification Number Effective Date
(mm/dd/yyyy)
/ /
CA:
FL:
AZ,
GA, KY,
NE
& NH:
KS:
LA:
NJ:
California law prohibits an HIV test from being required
or used by health insurance companies as a condition of
obtaining health insurance coverage.
Any person who knowingly, and with intent to injure,
defraud, or deceive any insurer les a statement of claim
or an application containing any false, incomplete or
misleading information is guilty of a felony of the third
degree.
All statements made by a Policyholder or by any Insured
Member shall be deemed representations and not
warranties, and no statements made for the purpose of
eecting coverage shall void such coverage or reduce
benets unless contained in writing and signed by the
Policyholder.
Any person who knowingly and with intent to defraud, as
stated on this Application, may be committing a fraudulent
insurance act which may be a crime.
Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benet or knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to nes and
connement in prison.
All statements made by applicant are true and complete
to the best of the applicant’s knowledge and belief. Any
person who includes any false or misleading information
on an application for an insurance policy is subject to
criminal and civil penalties.
NY:
OR:
OR:
TN:
UT:
VA:
Any person who knowingly and with intent to defraud any
insurance company or other person les an application for
insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits
a fraudulent insurance act, which is a crime and shall also be
subject to a civil penalty not to exceed ve thousand dollars
and the stated value of the claim for each such violation.
Any person who knowingly and with intent to defraud, as
stated on this Application, may be committing a fraudulent
insurance act which may be a crime.
Contestability is limited to two years as stated in the Group
Policy.
It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
Any matter in dispute between you and the company may be
subject to arbitration as an alternative to court action pursuant
to the Rules of (the American Arbitration Association or other
recognized arbitrator), a copy of which is available on request
from the company. Any decision reached by arbitration shall
be binding upon both you and the company. The arbitration
award may include attorney’s fees if allowed by state law
and may be entered as a judgement in any court of proper
jurisdiction.
Any person who within the intent to defraud or knowing
that he is facilitating a fraud against an insurer, submits an
application or les a claim containing a false or deceptive
statement may have violated the state law.
— 3 —
• UnitedConcordiaDentalCorporationofAlabama—AL
• UnitedConcordiaDentalPlans,Inc.—DC,MD,NJ
• UnitedConcordiaDentalPlansofCalifornia,Inc.—CA
• UnitedConcordiaDentalPlansofFlorida,Inc.—FL
• UnitedConcordiaDentalPlansofKentucky,Inc.—KY
• UnitedConcordiaDentalPlansoftheMidwest,Inc.—MI,MO,OH
• UnitedConcordiaDentalPlansofPennsylvania,Inc.—PA
• UnitedConcordiaDentalPlansofTexas,Inc.—TX
• UnitedConcordiaInsuranceCompany—AK,AR,AZ,CA,CO,
C
T, FL, GA, HI, IA, ID, IN, KS, LA, MA, MD, ME, MI, MN, MS, MT, NE,
NH,NV,NM,ND,OH,OK,OR,RI,SC,SD,TN,TX,UT,VT,VA,WA,
WV,WY
• UnitedConcordiaLifeandHealthInsuranceCompany—DE,DC,
IL, KY, MD, MO, NC, NJ, PA
• UnitedConcordiaInsuranceCompanyofNewYork—NY
United Concordia operates as a wholly owned subsidiary under
the name listed below in the following states:
Program Availability
•ProductsarenotavailableinanystatewhereprohibitedbylaworwhereUnitedConcordia
does not have regulatory approval.
•DomesticpartnercoverageisnotpermittedinIdaho.
State Mandated Provisions
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
⨀G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
English
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
esvakmPasa\tKitéfø . GñkGacTTYl)anGñkbkERbPasa nigGanÉksarCUnGñkCa PasaExr . sRmab;CMnYy sUmTUrs½BÞmkeyIg´tamelxEdlman
bgðajelIb½NÑsMKal;xøÜnrbs;Gñk b¤elx
XXX-XXX-XXXX . sRmab;CMnYybEnßmeTot sUmTUrs½BÞeTARksYgFanara:b;rgrdækalIhV½rj:a
1-800-927-4357 Khmer
ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis XXX-XXX-XXXX. Yog xav
tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong
Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para
obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al
Departamento de Seguros de CA al 1-800-927-4357. Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Ζױאشխ֮ނ֮ٙആ࿯൞ᦫΔڶࠄ֮ٙڶխ֮ऱठءΔՈױאނຍࠄ֮ٙബ࿯൞Ζ
඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽʳʳ
1-800-927-4357 ፖףڠঅᙠຝᜤ࿮Ζʳ
Chinese
ʳ
ʳ
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch. Quyù vò coù theå ñöôïc ngöôøi khaùc ñoïc
giuùp caùc taøi lieäu vaø nhaän moät soá taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû
hoäi vieân cuûa quyù vò hoaëc XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357.
Vietnamese
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin. Maaari mong ipabasa sa iyo ang mga
dokumento at maaari mong hingin na ipadala ang ilang mga dokumento sa iyo sa Tagalog. Para makakuha ng tulong, tawagan kami sa
numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa
1-800-927-4357.
Tagalog
G䋩G㉐⽸㏘UGỴ䚌⏈G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㏩⏼␘UG䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘Gⵏ㡰㐘G㍌G㢼㡰⮤G
䚐ạ㛨⦐Gⶼ㜡═G㉐⪌⪰Gⵏ㙸⸨㐘G㍌⓸G㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨GG
㤸䞈aGTTⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G㣄㉬䚐Gⱬ㢌G㇠䚡㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈GG
1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘UG
Korean
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language.
For help, call us at the number listed on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at
1-800-927-4357.
English
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Ζױאشխ֮ނ֮ٙആ࿯൞ᦫΔڶࠄ֮ٙڶխ֮ऱठءΔՈױאނຍࠄ֮ٙബ࿯൞Ζ
඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽʳʳ
1-800-927-4357 ፖףڠঅᙠຝᜤ࿮Ζʳ
Chinese
ʳ
ʳ
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch. Quyù vò coù theå ñöôïc ngöôøi khaùc ñoïc
giuùp caùc taøi lieäu vaø nhaän moät soá taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû
hoäi vieân cuûa quyù vò hoaëc XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357.
Vietnamese
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin. Maaari mong ipabasa sa iyo ang mga
dokumento at maaari mong hingin na ipadala ang ilang mga dokumento sa iyo sa Tagalog. Para makakuha ng tulong, tawagan kami sa
numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa
1-800-927-4357.
Tagalog
G䋩G㉐⽸㏘UGỴ䚌⏈G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㏩⏼␘UG䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘Gⵏ㡰㐘G㍌G㢼㡰⮤G
䚐ạ㛨⦐Gⶼ㜡═G㉐⪌⪰Gⵏ㙸⸨㐘G㍌⓸G㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨GG
㤸䞈aGTTⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G㣄㉬䚐Gⱬ㢌G㇠䚡㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈GG
1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘UG
Korean
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
No Cost Language Services. You can get an interpreter and get documents read to you in your language. For help, call us at the
sted on your ID card or XXX-XXX-XXXX. For more help call the CA Dept. of Insurance at 1-800-927-4357
Servicios de idiomas sin costo. Puede obtener un intérprete y que le lean los documentos en español. Para obtener ayuda, llámenos al
número que figura en su tarjeta de identificación o al XXX-XXX-XXXX. Para obtener más ayuda, llame al Departamento de Seguros
de CA al 1-800-927-4357.
Spanish
܍
၄፿ߢࣚ೭Ζ൞ױᛧ൓Ց᤟୉ࣚ೭Δشխ֮ނ֮ٙആ࿯൞ᦫΖ඿࠷൓࠰ܗΔᓮીሽ൞ऱঅᙠ׬ࢬ٨ऱሽᇩᇆᒘΔࢨᐸؚ
XXX-XXX-XXXX ፖݺଚᜤ࿮Ζ඿࠷൓ࠡה࠰ܗΔᓮીሽ1-800-927-4357 ፖףڠঅᙠຝᜤ࿮ΖChinese
Caùc Dòch Vuï Trôï Giuùp Ngoân Ngöõ Mieãn Phí. Quyù vò coù theå ñöôïc nhaän dòch vuï thoâng dòch vaø ñöôïc ngöôøi khaùc ñoïc giuùp caùc
taøi lieäu baèng tieáng Vieät. Ñeå ñöôïc giuùp ñôõ, haõy goïi cho chuùng toâi taïi soá ñieän thoaïi ghi treân theû hoäi vieân cuûa quyù vò hoaëc
XXX-XXX-XXXX. Ñeå ñöôïc trôï giuùp theâm, xin goïi Sôû Baûo Hieåm California taïi soá 1-800-927-4357. Vietnamese.
G䋩G㉐⽸㏘UGỴ䚌⏈G䚐ạ㛨G䋩㜡G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G㢼㡰⮤G䚐ạ㛨⦐G㉐⪌⪰G⇡⓹䚨㨰⏈G㉐⽸㏘⪰Gⵏ㡰㐘G㍌G
㢼㏩⏼␘UG⓸㟴㢨G䙸㟈䚌㐔G⺸㡴GỴ䚌㢌GpkG㾨☐㜄G⇌㝴㢼⏈G㙼⇨G㤸䞈aGXXX-XXX-XXXXⶼ㡰⦐Gⱬ㢌䚨G㨰㐡㐐㝘UG⸨␘G
㣄㉬䚐G㇠䚡㡸Gⱬ㢌䚌㐘G⺸㡴G㿌⫠䔠⏼㙸G㨰G⸨䜌ạSG㙼⇨G㤸䞈G1-800-927-4357ⶼ㡰⦐G㜤⢱䚨G㨰㐡㐐㝘U Korean
Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga
dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa XXX-XXX-XXXX. Para sa
karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357
Tagalog
             
       ID)    
XXX-XXX-XXXX    1-800-927-4357   
 Armenian
         
              
  XXX-XXX-XXXX      
   Department of Insurance  1-800-927-4357. Russian
ᢱ䬽⸒⺆䭼䯃䮚 ᣣᧄ⺆䬶ㅢ⸶䭡䬣ឭଏ䬦䫺ᦠ㘃䭡䬙⺒䭎䬦䭍䬨䫻䭼䯃䮚䮀䭡䬣Ꮧᦸ䬽ᣇ䬾䫺䎃ID䭲䯃䮐⸥タ䬽⇟ภ䭍䬮䬾䎃
XXX-XXX-XXXX 䭍䬶䬙໧䬓ว䭞䬪䬞䬯䬤䬓䫻ᦝ䬹䭚䬙໧䬓ว䭞䬪䬾䫺䎃䭲䮱䮜䭰䮲䮒䭩Ꮊ଻㒾ᐡ䫺1-800-927-4357䭍䬶䬣䎃
ㅪ⛊䬞䬯䬤䬓䫻
Japanese
                     
                 XXX-XXX-XXXX     
CA Dept. of Insurance   1-800-927-4357 Persian
                      
     ID      XXX-XXX-XXXX      
      1-800-927-4357    Punjabi
XXX-XXX-XXXX
CALAP-FFS-LP-1208
United Concordia would like to make it as easy as possible to use and understand your dental benets. To help us do that, please complete the
preference form located on the back and return with your completed enrollment form if you have not already provided us this information. All
information will be kept condential and is not a requirement in order to receive dental benets.
United Concordia quiere facilitarle lo más posible la comprensión y la utilización de sus benecios dentales. Para ayudarnos a lograrlo, llene
el formulario de preferencia que aparece al reverso y envíelo con su formulario de inscripción completado si todavía no nos ha proporcionado
esta información. Toda la información se mantendrá condencial y no es un requisito para poder recibir benecios dentales.
Employee ID Number, i.e. Social Security Number
(Numero de identificación del empleado, es decir, número del Seguro Social)
___–__–____
Covered Member A
(Afiliado cubierto A)
Name ________________
(Nombre)
Covered Member B
(Afiliado cubierto B)
Name ________________
(Nombre)
Covered Member C
(Afiliado cubierto C)
Name ________________
(Nombre)
Covered Member D
(Afiliado cubierto D)
Name _______________
(Nombre)
Spoken language
preference
(Idioma hablado de
preferencia)
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
Written language
preference
(Idioma escrito de
preferencia)
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
English (Inglés)
Spanish (Español)
Chinese (Chino)
Korean (Coreano)
Tagalog (Tagalo)
Vietnamese (Vietnamita)
Declined to state
(Prefiere no declararlo)
Other, please specify
(Otro, por favor especificar)
_________________________
Choose one to best
represent the covered
member
(Elija uno que
represente mejor al
afiliado cubierto)
American Indian/Alaska native
(Indígena americano/Indígena
de Alaska)
Asian (Asiático)
Black/African American
(Negro/Afroamericano)
Native Hawaiian/Pacific Islander
(Indígena hawaiano/Oriundo de
las Islas del Pacifico)
White/Caucasian
(Blanco/Caucásico)
Other, please specify
(Otro, por favor especificar)
________________________
Declined to state
(Prefiere no declararlo)
American Indian/Alaska native
(Indígena americano/Indígena de
Alaska)
Asian (Asiático)
Black/African American
(Negro/Afroamericano)
Native Hawaiian/Pacific Islander
(Indígena hawaiano/Oriundo de las
Islas del Pacifico)
White/Caucasian
(Blanco/Caucásico)
Other, please specify
(Otro, por favor especificar)
________________________
Declined to state
(Prefiere no declararlo)
American Indian/Alaska native
(Indígena americano/Indígena
de Alaska)
Asian (Asiático)
Black/African American
(Negro/Afroamericano)
Native Hawaiian/Pacific Islander
(Indígena hawaiano/Oriundo de
las Islas del Pacifico)
White/Caucasian
(Blanco/Caucásico)
Other, please specify
(Otro, por favor especificar)
________________________
Declined to state
(Prefiere no declararlo)
American Indian/Alaska native
(Indígena americano/Indígena
de Alaska)
Asian (Asiático)
Black/African American
(Negro/Afroamericano)
Native Hawaiian/Pacific Islander
(Indígena hawaiano/Oriundo de
las Islas del Pacifico)
White/Caucasian
(Blanco/Caucásico)
Other, please specify
(Otro, por favor especificar)
________________________
Declined to state
(Prefiere no declararlo)
Choose one to best
represent the covered
member
(Elija uno que
represente mejor al
afiliado cubierto)
Hispanic/Latino
(Hispano/Latino)
Non-Hispanic/Non-Latino
(No Hispano/No Latino)
Declined to state
(Prefiere no declararlo)
Hispanic/Latino
(Hispano/Latino)
Non-Hispanic/Non-Latino
(No Hispano/No Latino)
Declined to state
(Prefiere no declararlo)
Hispanic/Latino
(Hispano/Latino)
Non-Hispanic/Non-Latino
(No Hispano/No Latino)
Declined to state
(Prefiere no declararlo)
Hispanic/Latino
(Hispano/Latino)
Non-Hispanic/Non-Latino
(No Hispano/No Latino)
Declined to state
(Prefiere no declararlo)
Please attach an additional form if you have more than 4 family members.
(Adjunte un formulario adicional si tiene más de 4 familiares).
Please attach an additional form if you have more than 4 family members.
(Adjunte un formulario adicional si tiene más de 4 familiares).
Mail: United Concordia
(Correo) Membership Services DP2
4401 Deer Path Rd
Harrisburg, PA 17109
Fax: 1-800-329-9093
(Fax)
TO SUBMIT
PARA ENVIAR
CANotice15570118(FFS)
Discrimination is Against the Law
The Plan complies with applicable Federal civil rights laws and does not discriminate, exclude people or
treat them differently based on race, color, national origin, ancestry, age, religion, disability, marital
status, gender, sex assigned at birth, sexual orientation, sex stereotypes, gender identity or recorded
gender. Furthermore, the Plan will not deny or limit coverage to any health service based on the fact that
an individual’s sex assigned at birth, gender identity, or recorded gender is different from the one to
which such health service is ordinarily available. The Plan will not deny or limit coverage for a specific
health service related to gender transition if such denial or limitation results in discriminating against a
transgender individual.
The Plan:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other
formats)
Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, call 1-800-332-0366 (TTY: 711) for assistance or contact the Civil Rights
Coordinator.
If you believe that the Plan has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, ancestry, age, religion, disability, marital status, gender, sex assigned
at birth, sexual orientation, sex stereotypes, gender identity or recorded gender, you can file a complaint
with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY:
711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmark.com. You can file a complaint in
person or by mail, fax, or email. If you need help filing a complaint, the Civil Rights Coordinator is
available to help you. You can also file a complaint with the California Department of Insurance
electronically through the Consumer Complaint Center, available at http://www.insurance.ca.gov/01-
consumers/101-help/index.cfm, or by mail or phone at:
California Department of Insurance
Consumer Services Division
300 S. Spring Street
Los Angeles, CA 90013
1-800-927-4357
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office
for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
CA LAP Taglines 0118
English
ATTENTION: If you speak English, you have the right to language assistance services at no charge to you,
including interpretation services and translated written documents in your preferred language. Call 1-800-332-
0366 (TTY: 711) for assistance.
Español
(Spanish)
ATENCIÓN: Si habla español, tiene derecho a servicios de asistencia lingüística sin coste alguno, incluidos
servicios de interpretación y traducciones de documentos escritos en la lengua que desee. Llame al 1-800-332-
0366 (TTY: 711) para más información.
繁體中文
(Chinese)
注意:如果您的語言是繁體中文,您有權免費使用語言協助服務,包括以您偏好的語言提供的口譯服務和翻譯的書
面文件。如需協助,請致電
1-800-332-0366 (TTY: 711)
Tiếng Vit
(Vietnamese)
LƯU Ý: Nếu quý v nói Tiếng Vit, bn s có quyn hưng min phí dch v h tr ngôn ng, bao gm dch v
phiên dch và tài liu bng văn bn đưc dch sang ngôn ng bn chn. Gi đin đến s 1-800-332-0366 (TTY:
711) đ đưc h tr.
Tagalog
(Tagalog)
PANSININ: Kung nagsasalita ka ng Tagalog, may karapatan ka sa mga serbisyong tulong sa wika nang wala kang babayaran,
kabilang ang mga serbisyo sa pagsasalin at mga nakasulat na dokumento na naisalin sa iyong pinipiling wika. Tumawag sa 1-
800-332-0366 (TTY: 711) para sa tulong.
한국어
(
Korean)
주의: 한국어를 사용하시는 경우, 원하는 언어로의 번역 비스 번역된 서면 문서를 포함하여, 언어 지원
서비스를
무료로
사용할
있습니다
.
도움이
필요하면
1-800-332-0366 (TTY: 711)
번으로
전화해
주십시오
.
Հայերեն
(Armenian)
ՈՒՇԱԴՐՈՒԹՅՈՒՆ
:
Եթե
Դուք
հայերեն
եք
խոսում
,
Դուք
իրավունք
ունեք
անվճար
ստանալ
լեզվական
աջակցության ծառայություններ, այդ թվում նաև՝ բանավոր թարգմանության և փաստաթղթերի գրավոր
թարգմանության ծառայություններ՝ Ձեր նախընտրած լեզվով: Օգնություն ստանալու համար
զանգահարեք
1-800-332-0366 (TTY
՝
711)
հեռախոսահամարով
:
فارسی
(Farsi)
توجه :اگر به زبان فارسی صحبت می کنيد، حق دارید از خدمات تسهيلات زبانی بصورت رايگان استفاده کنید، از جمله خدمات
ترجمه شفاهی و اسناد کتبی ترجمه شده به زبان انتخابی خودتان. با 1-800-332-0366 (تله تایپ: 711) تماس بگيريد
Русский
(Russian)
ВНИМАНИЕ: Пользователям, разговаривающим на русском языке, бесплатно предоставляются службы
языковой поддержки, включая услуги устного перевода и письменного перевода документов на
предпочитаемый язык. Тел. службы поддержки 1-800-332-0366 (TTY: 711).
日本語
(Japanese)
注意事項:日本語をお使いの方は、言語面でのサポートを無償でご利用いただけます。サービスには、選択され
た言語による通訳や文書の翻訳も含まれます。サポートが必要な場合は、1-800-332-0366 (TTY: 711)まで、お電
話にてご連絡ください。
العربية
(Arabic)
تنبيه: إذا كنت تتحدث العربية، لديك الحق في الحصول على خدمات المساعدة اللغوية
ً
ﻧﺎﺠﻣ، بما في ذلك خدمات الترجمة
والمستندات المكتوبة المترجمة بلغتك المفضلة. اتصل على الرقم 0366-332-800-1 (خدمة الرسائل النصية: 711) للحصول
على المساعدة.

(Punjabi)
 :     ,            ,      
              1-800-332-0366 (TTY: 711)  


(
Cambodian)
   
  1-800-332-0366 (TTY: 711) 
ນເຜ
າລາວສ
(Hmong)
ໝາຍເຫດ: ຖ້າທ່ານເວົ້າພາສາມົ້ງ, ທ່ານມີສິດໄດ້ຮັບກາບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໂດຍ
ບໍ່ເສຍຄ່າ ເຊິ່ງລວມມີການບໍລິການລ່າມແປພາສາ ແລະ ການແປເອກະສານເປັນລາຍລັກອັກສອນເປັນ
ພາສາທີ່ທ່ານເລືອກ. ກະລຸນາໂທຫາເບີ 1-800-332-0366 (TTY: 711) ເພື່ອຂໍຄວາມຊ່ວຍເຫຼືອ.

(Hindi)


:





,
















,
           
  .    1-800-332-0366
(TTY: 711)   .

(Thai)
  









1-800-332-0366 (TTY: 711)
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