ST 7534 Ed. 9-07 Dental 050809LPage 1 of 1
group insurance form
Policy and Div. # 160- ___________________ Cert. #____________________
Name and Address of Employer (Policyholder) ___________________________________________________________________________
to enroll Dental To terminate all coverages
employee information Marital Status Single Married
Social Security number ____________________________ Employee’s last name, fi rst name, MI ________________________________
Date of birth _____________________________________________ Male Female
Full time date of hire ______________________________________ Rehire: Rehire date ____________________________________
Street address ___________________________________________ City _________________________ State______ ZIP____________ E-
mail address (limit of 60 characters) __________________________________________________________________________________
Are you covered under another dental insurance plan? . . . . . . . . . . . . . . . . . Employee: Yes No Dependents: Yes No
dependent coverage information List all eligible dependents to be added or deleted. (Employee must be enrolled to cover dependents)
print full legal name (last, fi rst. MI) add drop relationship sex date of birth social security number
please sign (employee/policyholder) The certifi cate provides dental benefi ts only. Review your certifi cate carefully.
As an employee, I hereby apply for, or waive (if indicated), group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct
premiums from my salary. THE FOLLOWING APPLIES ONLY TO SECTION 125 FLEXIBLE BENEFITS PLANS: I am signing up for coverage until the next enrollment period except in the case
of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I represent that the information I have provided is complete and accurate
to the best of my knowledge. The policyholder certifi es the date of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.
Employee Signature (do not print) Date
Policyholder Signature (do not print) Date
In several states, we are required to advise you of the following: Any person who knowingly and with intent to defraud provides false, incomplete, or misleading information in an applica-
tion for insurance, or who knowingly presents a false or fraudulent claim for payment of a loss or benefi t, is guilty of a crime and may be subject to fi nes and criminal penalties, including
imprisonment. In addition, insurance benefi ts may be denied if false information provided by an applicant is materially related to a claim. (State-specifi c statements on back.)
Employee late entrant date _________________________________
Dependent late entrant date ________________________________
Effective Date Class Dep. Code
to change
Name change New Name _______________________________________ Old Name____________________________________
Add dependent coverage
If due to marriage, what is the date of marriage? ____________________________________________________________________
If due to birth/adoption, what is the date of event?___________________________________________________________________
If due to loss of coverage, date and reason: ________________________________________________________________________
If other, the date of event and please explain: ______________________________________________________________________
Drop dependent coverage Number of dependents still covered: ______ Effective date of drop: _________________________
Due to divorce Due to death Due to annual election period
Other (please explain) __________________________________________________________________________________________
to waive
WITH YOUR EMPLOYER. I have been given an opportunity to apply for Group Insurance offered by my employer, and have decided not to accept the offer for:
myself (does not apply to TRUST policies) spouse only child(ren) only spouse and child(ren)
because ___________________________________________________________________________________________________________
Name of insurance company and employer of dependent __________________________________________________________________
Should I desire to apply for this group insurance in the future, I realize that a “late entrant” penalty may be applied.
individual is
a continuee:
Qualifying event ___________________
Date of event _____________________
P.O. Box 82622 / Lincoln, NE 68501-2622
877-490-9991 / Fax: 402-467-7338
Insurance Company
Presbyterian College
ST 7534 Ed. 9-07 Dental 050809L
for fi 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 identi er 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 e ective date
is calculated for new members.
Class Number – needed when the plan has more than one class of
To change
Changing Dependent Codes – When adding or dropping depen-
dents, 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
speci c when changing status so all dependents who are still eligible
will be covered.
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 di cult or impossible to
scan.  e following list of helpful hints will make your forms easier
to scan:
1) submit clear, legible enrollment forms.
2) underline or circle important information.
3) use blue or black ink.
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.  is information is not
always captured on the image system.
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 identi cación o al
877-233-2797. 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,  nes, 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  les a statement of
claim or an application containing any false, incomplete, or mislead-
ing information is guilty of a felony of the third degree.
Note for Georgia, Oregon and Virginia Residents: Any person
who, with intent to defraud or knowing that he is facilitating a fraud
against insurer, submits an application or  les a claim containing a
false or deceptive statement may have violated state law.
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 Residents: Any person who knowingly presents
a false or fraudulent claim for payment of a loss or bene t or know-
ingly presents false information in an application for insurance is guilty
of a crime and may be subject to civil  nes and criminal penalties.
Note for Pennsylvania Residents: Any person who knowingly and
with intent to defraud any insurance company or other person,  les
an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of mislead-
ing 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 Washington, D.C. Residents: Any person who know-
ingly and willfully presents a false or fraudulent claim for payment
of a loss or bene t or who knowingly and willfully presents false
information in an application for insurance is guilty of a crime and
may be subject to  nes and con nement in prison.