Altus Dental Insurance Company, Inc.
PO Box 1557
Providence, RI 02901-1557
II. GROUP INFORMATION
Employer / Group Name Group No. Division No. Date of Hire Location No. (if applicable)
III. ENROLLMENT INFORMATION
EFFECTIVE DATE OF ACTION (MM/DD/YYYY)
Birth or Adoption
Return from Leave of Absence
Loss of Coverage
Death of a Member
Changes typically made
on the rst of the month.
Add Dependent to Family
List name in Section IV
Name / Address Change
Transfer from Sublocation # ___________ to # ___________
Change Type of Coverage (Please indicate change, e.g. Individual to
Family, in “Type of Coverage” section below.)
Reinstatement of Subscriber
Addition of Dependent
Prior ID # ___________
TYPE OF COVERAGE
Individual Individual & Spouse Individual & Child(ren) Family
I. SUBSCRIBER INFORMATION
Subscriber Name (First, Last) Date of Birth (MM/DD/YYYY) Social Security / I.D. #
Street Address / P.O. Box No. Apt. No. City State Zip
IV. DEPENDENT INFORMATION
First Name Last Name (if dierent)
Date of Birth
Check if student
VI. COORDINATION OF BENEFITS
Are you or any of your dependents covered by another DENTAL plan? No Yes If Yes, please complete the section below.
Policyholder Name (First, Last) Policyholder I.D. No. Group I.D. No.
Dental Insurance Company Dental Insurance Address (Street, City, State, Zip)
Employer Name (through which you/your dependents have coverage)
I certify that all information is correct to the best of my knowledge. I understand that the eective date and termination date of my membership will be determined by my
employer or plan sponsor in accordance with underwriting guidelines. If my employer requires employee contributions for this coverage, I authorize the deductions of
these amounts from my wages periodically.
___________________________________________ ____________ ___________________________________________ ____________
Employee Signature Date Benets Administrator Authorization Date
NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY POLICY
Altus Dental does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-223-0588.
Português (Portuguese): ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para 1-877-223-0588.
Group must have student rider.
Rev0120 MM/YY - QTY [BUG]
V. DENTIST INFORMATION List the dentist(s) you or your covered family members use.
Dentist(s) Last Name, First Name City / Town Patient(s) Last Name, First Name