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PLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE FORM
Domestic
Partner
Spouse
Form must be Completed in Full, Signed and Dated for processing.
If you are waiving coverage, you must complete, sign and date waiver on page 4
of this application.
E-mail address: memberprocessing@choicebuilder.com
(1 of 5)
A. PERSONAL INFORMATION
Dental / Vision / Chiropractic / Life
Enrollment Form
Group #
B
Enrolling For?
Last Name
First Name
Social Security #
Date of Birth
Gender
Dental
Dental Dental
Disabled?
Male Female Male Female Male Female Male Female
Yes No Yes No Yes No
Relationship to Employee
COBRA APPLICANTS
Please check COBRA type:
Indicate Qualifying/Triggering Event
Physical Address (Do not use P.O. Box) Apt. # City
State ZIP Code
Employee First Name
M.I.
Date of Birth (MM/DD/YYYY)
Employee Last Name
Employee Social Security #
Social Security # required
(MM/DD/YYYY)
Employee Spouse/Domestic Partner Child Child Child
(MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY)
Social Security # required Social Security # required Social Security # required
Date of Qualifying/Triggering Event
(MM/DD/YYYY)
Company Name Company Phone # (XXX) XXX-XXXX
Employee Job Title
Full-Time Employment Date (MM/DD/YYYY)
State ZIP Code
Gender
M F
Status
Married Single
Domestic Partner
If you are an existing member, and are changing dental plans or adding a plan, please use an Employee "Change Request Form".
For Primary Dental Office changes only, please contact your dental plan directly.
Phone # (XXX) XXX-XXXX
E-mail Address
(Complete only if over age 26)
B. ENROLLMENT INFORMATION
Complete this section ONLY if you are electing dental, vision and/or chiro for yourself and dependents.
*If you are enrolling a disabled dependent you must complete a Disabled Dependent Form. (form can be found on the ChoiceBuilder website)
Vision
Chiro
Vision Vision
Dental
Vision
Dental
Vision
Please select one:
New Hire Enrollment New Renewal Enrollment
New COBRA Enrollment
Qualifying/Triggering Event
Termination of employment
Reduction of hours
Child no longer eligible
Divorce/legal separation
Medicare entitlement
Death of employee
Mailing Address
Apt. # City
(if different from above)
COBRA
Cal-COBRA
®
CB 0310A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
721 South Parker, Suite 200, Orange, CA 92868
Phone: (866) 412-9279 • Fax (866) 412-9280
www.choicebuilder.com
64490
C. DENTAL BENEFIT
(2 of 5)
Print Employee Name Group #
B
Gold Silver Bronze
DeltaCare USA DHMO
OR
PPO
Platinum Plus Platinum Gold Silver
Select a Dental Office (DHMO ONLY)
(If the Dental Office selected is not available or one was not selected, the Dental Office will be assigned.)
Last Name
First Name
Dentist Name/Office
City
Check here if you would like your Dental Plan to assign you a Primary Dental Office.
To enroll more dependents, complete sections A & B on an additional Enrollment Form.
Æ
If changing dental plans or adding a plan, please select a Primary Dental Office. A Primary Dental Office is not required for PPO benefit plans. If a
Primary Dental Office is not contracted with your selected Dental Plan prior to enrolling or if a Primary Dental Office is not listed, one will automatically be
assigned to you. For Primary Dental Office changes only, please contact your Dental Plan directly.
*
Child
Child
Child
Spouse/Domestic Partner
Employee
D. OPTIONAL BENEFITS -
Sections A, B & E of this form must be completed for all Optional Benefits.
Ask your dental plan administrator if any of the optional benefits below are being offered by your employer
* If you are listing more than one primary beneficiary or more than one secondary beneficiary, please enter the percentage of the insurance proceeds that
each individual should receive. The percentage of insurance proceeds must equal 100% for each type of beneficiary (primary or secondary). No secondary
beneficiaries will be entitled to any part of the insurance proceeds if any primary beneficiary is living at the time of death of the insured.
Current Patient?
Yes No Yes No Yes No Yes No Yes No
Dentist I.D. #
(see worksheet for plan availability)
Select
ONE
plan
Premium Only Plan (P.O.P)
I want my portion of eligible insurance premiums paid on a pre-tax basis
LIFE
Complete only if your employer has selected life coverage.
Beneficiary Name(s)
Last Name First Name
M.I.
Date of Birth
Relationship to You
(i.e. spouse, friend, child)
*Percentage
*Type of
Beneficiary
Primary
Secondary
Primary
Secondary
Primary
Secondary
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
Vision: Select ONE plan
(see worksheet for plan availability)
Platinum Gold Silver
(Silver not available with VSP Voluntary)
CHIROPRACTIC (see worksheet for plan availability)
Check this box to add Voluntary Chiropractic coverage
CB 0310A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
®
64490
E. YOUR LEGAL ACKNOWLEDGEMENT
(3 of 5)
(Read, sign and date where indicated)
My signature acknowledges both my understanding of the information presented above as well as the decision to enroll in the coverage(s) I have
selected.
FOR LANDMARK
HEALTHPLAN ENROLLEES ONLY:
FOR ALL ENROLLEES:
Terms and conditions of enrollment are
described in your Landmark Health Plan of
California, Inc. (the “Plan”) Combined Evidence
of Coverage and Disclosure Form, and the
Group Agreement between the Plan and your
Employer Group.
In the event that this application for coverage
is accepted, I authorize my health care
practitioner, as permitted by law, to provide the
Plan with information concerning the health
condition or treatment of any enrollee named
above, as required for the Plan to authorize or
pay for covered services provided by such
practitioner.
I further authorize the Plan and any other health
care plan through which I and/or my
dependents have coverage to release any
information to one another that would be
necessary to coordinate benefits between or
among the plans.
With regard to the authorizations above, I agree
that a copy of this form shall be valid as the
original.
I agree and understand that any and all
disputes, including claims relating to the
delivery of services under the plan and claims
of medical malpractice (that is as to whether
any medical services rendered under the health
plan were unnecessary or unauthorized or were
improperly, negligently, or incompetently
rendered), except for claims subject to ERISA,
between myself and my dependents enrolled in
the plan (including any heirs or assigns) and
Landmark Health Plan of California, Inc., or any
of its parents, subsidiaries, or affiliates shall be
determined by submission to binding arbitration.
Any such dispute will not be resolved by a
lawsuit or resort to court process, except as the
federal arbitration act provides for judicial
review of arbitration proceedings. All parties to
this agreement are giving up their constitutional
right to any such dispute decided in a court of
law before a jury, and instead are accepting the
use of binding arbitration.
Print Name
Signature
X
YOU MUST COMPLETE SECTIONS A-E IN ORDER FOR YOUR FORM TO BE PROCESSED
Date (MM/DD/YYYY)
I agree for myself and my dependents to be bound by the benefits, co-pays,
deductibles, exclusions, limitations and other terms of the health plan’s small group
contract as administered by the state of California.
I declare under the penalty of perjury under the laws of the state of California that
the followinsg statements are true, correct and pertain to the employer named on
this form, myself and my dependents named on this form.
I am considered eligible by my employer because I am a full-time employee
who works the required number of hours per week.
If I am an eligible employee applying for coverage outside of a renewal
period, I have had a change in family status or have experienced another
qualifying/triggering event that qualifies either me or my dependent(s) as a
“Late enrollee” pursuant to California law.
I am not a temporary, seasonal, per diem, 1099 or substitute employee or
insured by or eligible to be insured by the employer's union policy.
My children’s dates of birth are accurate. My children meet all eligibility
requirements. I understand that the preceding statements are subject to
audit at any time and agree to provide ChoiceBuilder with any and all
information necessary to prove the above statements.
All statements and answers I have given are true and complete.
I understand it is a crime to knowingly perform an act or practice constituting
fraud or make an intentional misrepresentation of material fact to an
insurance company for the purposes of defrauding the company. Penalties
may include imprisonment, fines or a denial of insurance benefits. I
understand all benefits are subject to conditions stated in the Group Contract
and coverage documents. If my plan is rescinded or canceled, I will receive
from my insurer a notice at least 30 days to the effective date of the
rescission explaining the reasons for the intended rescission and my rights to
appeal that decision to the Commissioner of Insurance pursuant to
subdivision (b) of Section 10273.4 of the California Insurance Code.
Notwithstanding subdivision (a) of Section 10273.4 or any other provision of
the law, I understand that after 24 months following the issuance of my
health plan or insurance policy, my insurer may not rescind my health plan or
insurance policy for any reason, and shall not cancel my health plan or
insurance policy, limit any provisions of the health plan or policy, or raise
premiums due to any omissions, misrepresentations, or inaccuracies in the
application for, whether willful or not.
I understand that any persons, business or health plan that suffers a loss
because of false declarations contained in this statement may take legal
action against me to recover their losses.
I authorize any payroll deduction that may be required towards the cost of
this coverage.
The representations made are the basis upon which coverage may be
issued.
California law prohibits HIV test from being required or used by health
insurance companies as a condition of obtaining health insurance coverage.
A policy of group health insurance shall provide equal coverage to employers
for the registered domestic partner of an employee, insured, or policyholder
to the same extent, and subject to the same terms and conditions, as
provided to a spouse of the employee, insured, or policyholder, and shall
inform employers of this coverage.
I have READ, UNDERSTAND and ATTEST that I myself and my dependents
have met all of the eligibility requirements.
•
•
•
•
•
•
•
•
•
•
•
CB 0310A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
®
64490
(for employer sponsored plans only, not required for voluntary plans)
(4 of 5)
IMPORTANT!
DENTAL and/or VISION WAIVER
Complete this page only if you DO NOT WANT DENTAL OR VISION COVERAGE for yourself and/or your eligible dependents (if
offered by your employer). If sponsored by your employer, the life coverage, chiropractic coverage, or chiropractic/acupuncture
coverage cannot be waived and you are required to complete a Dental / Vision / Chiropractic / Life Enrollment Form.
Company Name
Group #
B
Personal Information
I have been offered coverage by my employer, but at this time I wish to DECLINE coverage as follows
1)
2)
Dental for
Vision for
Myself and Dependents Spouse Domestic Partner Child(ren)
Myself and Dependents Spouse Domestic Partner Child(ren)
Type of Waiver
Reason
Carrier Name
1)
Required only if employee waiving coverage — not required if waiving coverage for dependents only
Other Group Coverage
Medicare
Medi-cal
Individual Policy
Other Reason
Reason waiving Dental
(explanation required)
Carrier Name
2)
Other Group Coverage
Medicare
Medi-cal
Individual Policy
Other Reason
Reason waiving Vision
(explanation required)
Signature
I understand that by waiving coverage now, ChoiceBuilder can impose up to a 12 month period of exclusion which would begin at the
time of my later decision to elect coverage.
I also understand that if my employer is sponsoring life coverage, chiropractic coverage, or chiropractic/acupuncture coverage, that I CANNOT
waive these coverages.
(Steps A-E MUST be completed if these benefits are being sponsored.)
This waiver provision will not apply if: 1) Court orders coverage of a spouse or child and the request for enrollment occurs within 60 days of the
court order; or 2) Employee meets ALL of the following: A) Was covered under another employer-sponsored health plan at the time of initial
eligibility; B) Has added a new dependent as a result of marriage, domestic partnership, birth, adoption, or placement for adoption and if
enrollment is requested within 60 days after the marriage, domestic partnership, birth, adoption or placement for adoption OR employee or eligible
dependents loses minimum health care coverage, for any reason other than due to failure to pay premiums, fraud, or intentional misrepresentation
of material fact; C) Requests enrollment within 60 days of loss of coverage.
ª
Employee SIGN HERE TO WAIVE COVERAGE
Employee Last Name
Employee First Name
Company Phone # (XXX) XXX-XXXX
Employee Social Security #
Print Name Date (MM/DD/YYYY)
CB 0310A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
®
64490
(5 of 5)
Family Coverage
Eligibility Requirements
Who can be covered?
If all required documentation is received
before the 16th day of the month of
marriage, premiums are charged for the
full month and coverage begins on the date
of marriage.
If all required documentation is received on
or after the 16th day of the month of
marriage, coverage begins on the 1st of
the month following the date of receipt.
Effective dates Requirements that MUST be met
■ New spouse must be legally married to the employee
■ New stepchild must also meet the dependent children requirements listed below
New Spouse/
New Stepchild
Birth/Adoption/
Legal Guardianship/
Eligible Dependent
Child
If birth/date of placement occurred
before the 16th of the month, coverage
begins on the first day of the month of the
date of birth/placement.
If birth/date of placement occurred on the
16th or after, child is automatically covered
at no cost under Subscriber between date
of birth/placement and the first of the
following month. Coverage for the
dependent begins on the first of the month
following the birth/date of placement.
■ Born to, a stepchild or legal ward of, adopted by eligible employee, employee
spouse or domestic partner
■ Financially dependent upon the employee per IRS guidelines
■ Unmarried or not involved in a domestic partnership
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
Disabled Dependents: Dependents who are incapable of self-support
because of continuous mental or physical disability that existed before the age
limit are eligible for coverage until the incapacity ends. Documentation of
disability will be requested. Once the child reaches the age limit for coverage,
verification of eligibility will occur annually at the child’s birthday.
Domestic Partner/
Child of Domestic
Partner
During Initial Enrollment or Group’s Annual
Renewal:
Coverage begins on group’s effective date.
Involuntary Loss of Other Coverage:
Domestic Partner can be added outside of
Renewal only if he/she loses other
coverage involuntarily. Coverage is
effective the first of following month.
Mid-Year Addition:
Mid-year additions of a domestic partner will
require a state-stamped copy of the
Declaration of Domestic Partnership from
the California Secretary of State within 60
days of issuance. If domestic partners have
filed a Declaration of Domestic Partnership
and have not yet received a copy from the
state, a signed Affidavit of Domestic
Partnership will be accepted. Domestic
Partners agree to provide a copy of the
Declaration of Domestic Partnership within
60 days of issuance. If all required
documentation is received before the 16th
day of the month in which the domestic
partnership was established, premiums are
charged for the full month and coverage
begins on the date of the event. If all
required documentation is received on or
after the 16th day of the month in which the
domestic partnership was established,
coverage begins on the 1st of the month
following the date of receipt.
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
Dependents must meet all requirements listed in order to be
eligible for enrollment
CB 0310A 11/2020 Eff. 3/1/2021
License # 0N14196 – ChoiceBuilder Insurance Services
For a Domestic Partner to qualify, Employee and Domestic Partner must:
Both have filed a duly executed Declaration of Domestic Partnership with the
Secretary of State and will provide copies to ChoiceBuilder within 60 days of
its issue.
Agree to notify ChoiceBuilder immediately upon termination of domestic
partnership.
Children of Domestic Partner must also meet the dependent children
requirements listed above
■
■
®
64490
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Completed 1 June 2021

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