deltadentalid.com
Enrollment/Change Form
Enrollment Form: Complete Sections I-III
Change Form: Complete Sections I-IV
I. EMPLOYEE INFORMATION
(PLEASE PRINT)
Subscriber Number or SSN# Date of Birth (mo/day/year)
o Male o Female
Name (First) (Middle Initial) (Last)
Mailing Address (PO Box or RR) City, State, Zip
Telephone #: Date Employed Full-time: # Hours Worked/Week: Marital Status:
E-mail Address:
Name of Employer:
II. DEPENDENT INFORMATION
(List all family members you wish to enroll)
III. OTHER DENTAL COVERAGE
(Medical coverage information is not required)
Change current enrollment due to: o Loss of previous coverage o Marriage o Divorce o Birth o Death o Other ____________________________________________ Date event occurred ____________________
Change my address to: Change my email to:
Change my name from:
IV. CHANGE REQUESTS
o Single o Divorced o Married o Widowed
Relationship to Applicant Dependent’s Name (First, MI, Last) Date of Birth (mo/day/year)SSN#
o Add
o Remove
o Spouse
o Stepchild
o Child
o Other
Relationship to Applicant Dependent’s Name (First, MI, Last) Date of Birth (mo/day/year)SSN#
o Add
o Remove
Relationship to Applicant Dependent’s Name (First, MI, Last) Date of Birth (mo/day/year)SSN#
o Add
o Remove
Relationship to Applicant Dependent’s Name (First, MI, Last) Date of Birth (mo/day/year)SSN#
o Add
o Remove
Relationship to Applicant Dependent’s Name (First, MI, Last) Date of Birth (mo/day/year)SSN#
o Add
o Remove
For Employer Use Eective Date:Group Number:
Are you and all dependents listed above on the plan?
o Yes o No If No, list covered dependents.
Name of Dental Carrier
Name of Covered Person
Do you or your dependents have dental coverage under another benefit pla ? o Yes o No
Date:
Date of Birth (mo/day/year)Relationship to YouName of Covered Person’s Place of Employment
Covered Person’s Group #Dental Carrier’s Address
To:
DELTA DENTAL OF IDAHO
If yes, please complete this section
By providing my email address, I agree to receive communications regarding my Policy electronically.
This authorization may be revoked by calling Customer Service at (800) 356-7586.
o Spouse
o Stepchild
o Child
o Other
o Spouse
o Stepchild
o Child
o Other
o Spouse
o Stepchild
o Child
o Other
o Spouse
o Stepchild
o Child
o Other
o Male
o Female
o Male
o Female
o Male
o Female
o Male
o Female
o Male
o Female
I hereby apply for the group coverage for which I may be eligible, and I authorize the release of my records to Delta Dental of Idaho.
I understand completion of this form does not guarantee eligibility and coverage will commence when all necessary documentation has been approved.
Employee Signature:
Delta Dental of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-(800) 356-7586.
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-(800) 356-7586.
DDI-ENROLL-1110
DELTA DENTAL OF IDAHO
555 E. Parkcenter Blvd
Boise, ID 83706
(208) 489-3580
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signature
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