ENROLLMENT FORM
Altus Dental Insurance Company, Inc.
PO Box 1557
Providence, RI 02901-1557
877-223-0588
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)
QUALIFYING EVENT
Open Enrollment
New Hire/Re-hire
Marriage
Divorce
Birth or Adoption
Workers’ Compensation
Return from Leave of Absence
Loss of Coverage
Full-Time/Part-Time Status
Death of a Member
ACTION CODE
Check one.
Changes typically made
on the rst of the month.
ADDITIONS
New Subscriber
Add Dependent to Family
Reinstatement
TERMINATION
Remove Subscriber
Remove Dependent
List name in Section IV
STATUS CHANGE
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.)
COBRA
Reinstatement of Subscriber
Addition of Dependent
Prior ID # ___________
TYPE OF COVERAGE
Check one.
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
Email Address
IV. DEPENDENT INFORMATION
First Name Last Name (if dierent)
Date of Birth
(MM/DD/YYYY) Relationship
Check if student
over 19
*
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.
4T
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
