Note for California Residents: California law prohibits an HIV test from
being required or used by health insurance companies as a condition of
obtaining health insurance coverage.
For group policies issued, amended, delivered, or renewed in California,
dependent coverage includes individuals who are registered domestic
partners and their dependents.
No Cost Language Services. You can get an interpreter and have
documents read to you in your language. For help, call us at the number
listed on your ID card or 877-233-3797. For more help call the CA Dept. of
Insurance at 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 gura en su tarjeta de identicación o al 877-233-3797. Para obtener
más ayuda, llame al Departamento de Seguros de CA al 800-927-4357.
Note for Colorado Residents: It is unlawful to knowingly provide false,
incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company.
Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company
who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of
Regulatory Agencies.
Note for Florida Residents: Any person who knowingly and with intent
to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is
guilty of a felony of the third degree.
Note for Georgia, Kansas, Nebraska, Oregon, Vermont and Virginia
Residents: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against insurer, submits an application or files a claim
containing a false or deceptive statement may have violated state law.
Note for Kentucky Residents: Any person who knowingly and with
intent to defraud any insurance company or other person files 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.
Note for Maryland Insureds: Any person who knowingly and willfully
presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an application
for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
Note for New Jersey Residents: Any person who includes any false
or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
Note for New Mexico and Rhode Island Residents: Any person
who knowingly presents a false or fraudulent claim for payment of a
loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to civil fines and
criminal penalties.
Note for North Carolina Residents: After 2 years from the date of
issue or reinstatement of this policy, no misstatements made by the
applicant in the application shall be used to void the policy or deny a
claim for loss commencing after the expiration of such 2 year period.
Note for Pennsylvania Residents: Any person who knowingly and
with intent to defraud any insurance company or other person, files 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 subjects such person to criminal and civil penalties.
Note for Tennessee Residents: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the
purposes of defrauding the company. Penalties include imprisonment,
fines and denial of coverage.
Note for Texas Residents: Any person who knowingly and with
intent to defraud provides false, incomplete or misleading information
in an application for insurance, or who knowingly presents a false or
fraudulent claim for payment of a loss or benefit, may be guilty of a
crime and may be subject to fines and criminal penalties, including
imprisonment. In addition, insurance benefits may be denied if false
information provided by an applicant is materially related to a claim.
Note for Washington, D.C. Residents: Any person who knowingly
presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
Note for Washington Residents: For groups policies issued, amended,
delivered, or renewed in Washington, dependent coverage includes
individuals who are registered domestic partners and their dependents.
tips for lling out this form
To Enroll
Missing, incomplete or illegible information can cause delays in adding
new employees to the system and could create errors in billing. To
ensure proper handling of your enrollment forms, please make sure the
following areas are completed:
• Policy Name and Group Number – to make sure plan members are
added to the correct group.
• Department/Division Numbers – so plan members are added in the
proper locations, and appear in the appropriate section on the billing if
the group has multiple departments or divisions.
• Social Security Numbers – the most important identifier for plan
members when calling in with claims or administrative questions.
Please double check to make sure your social security number is
accurate and written clearly.
• Full-time Employment Date – needed so the correct effective date is
calculated for new members.
• Class Number – needed when the plan has more than one class of
employees.
To Change
Changing Dependent Codes – When adding or dropping dependents,
please note whether this change is because of a “life event” or for some
other reason. (Examples of life events: marriage, birth of a child, divorce
. . . ) Please remember to include the date of the event. Late entrant
status will be applied if a life event is not included. Be specific when
changing status so all dependents who are still eligible will be covered.
Imaging
In order to provide better service, our administration system utilizes image
technology. In the image environment, we scan your enrollment forms into
our system, making them easier and faster to access. Better quality forms
help us to process your enrollments faster. Unfortunately, certain forms
are difficult or impossible to scan. The following list of helpful hints will
make your forms easier to scan:
Do:
1) submit clear, legible enrollment forms.
2) underline or circle important information.
3) use blue or black ink.
Don’t:
1) submit dark copies as they appear black on imaging.
2) highlight, which blackens the area so it cannot be read.
3) write on the top or bottom margins. This information is not always
captured on the image system.
GR 875 Rev. 06-12 Page 2 of 2 Dental - High/Low 10-30-13
