a COBRA member: (select a box below)
18 months
29 months
36 months
Date of Continuation Qualifying
Event:
a current member: (select a box below)
changing my name
changing my address
changing my dependents
terminating my coverage
due to...
open enrollment
qualifying event (marriage, adoption, birth, loss of other coverage)
Dental Enrollment Application
and Change of Information Form
Willamette Dental of Idaho, Inc.
6950 NE Campus Way, Hillsboro, Oregon 97124
Please print your answers clearly in ink and ll out both sides of this form so we can process your
application quickly. Thank you.
I’m lling out this application because I am...
1
a new applicant
My employer information is...
2
Name of Employer Group ID Effective Date
Address City State Zip Code
Work Telephone Number Occupation Date of Hire
I want to enroll my...
4
Legal Spouse (Last, First, Middle Initial)
Social Security Number Gender
Date of Birth
/ /
Dependent Child (Last, First, Middle Initial)
Social Security Number Gender
Date of Birth
/ /
Dependent Child (Last, First, Middle Initial)
Social Security Number Gender
Date of Birth
/ /
Dependent Child (Last, First, Middle Initial) Social Security Number Gender
Date of Birth
/ /
Please continue application on back...
M F
M F
M F
Add Delete
Add Delete
a retiree
My information is...
3
Self (Last, First, Middle Initial) Social Security Number Gender
Home Address City/State/Zip Home Telephone Number
E-mail Address Date of Birth
/ /
Old Name, if applicable
M F
Add Delete
M F
Add Delete
Form No. 003R-ID (1/12)
Bonneville County
605 N Capital Ave
Idaho Falls
ID
83402
Other dental insurance I have...
6
Are you or any of your dependents covered by another dental plan?
Yes No
If yes, name of enrollee:
Name of Carrier: Policy Number:
Waiving your group dental insurance...
Do you wish to waive the right to group dental insurance offered through your employer?
Yes No
If yes, please choose who you are waiving coverage for below:
Myself & my dependents My dependents only
Signature: Date: / /
Signatures
7
I hereby apply for coverage through Willamette Dental of Idaho, Inc. for myself and for my listed dependents.
I authorize my employer to make payroll deductions from my salary or wages in the amount required, if any, to cover
my contribution to coverage with Willamette Dental of Idaho, Inc. I authorize any provider of health services to give
Willamette Dental of Idaho, Inc., upon request, any information concerning the health, condition, or treatment of any
person included under such coverage whenever such information is considered necessary for the proper disposition of a
claim in fulllment of obligations imposed on Willamette Dental of Idaho, Inc. by State or Federal law.
I certify that all information supplied in this application is true and complete to the best of my knowledge. I agree to
advise Willamette Dental of Idaho, Inc. of any change in status within 60 days from the date of change. Limited to two
years within ling this form, I understand that my coverage is null and void if I have provided any information which is
false or misleading regarding myself or my dependents on this form or any form led in conjunction with this plan.
Signature of Primary Applicant Date of Signature
Dental Enrollment Application Continued...
Dependent Child (Last, First, Middle Initial)
Social Security Number Gender
Date of Birth
/ /
Dependent Child (Last, First, Middle Initial)
Social Security Number Gender
Date of Birth
/ /
Dependent Child (Last, First, Middle Initial) Social Security Number Gender
Date of Birth
/ /
M F
M F
Add Delete
Add Delete
M F
Add Delete
Additional dependents...
5
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