ENROLLMENT APPLICATION – SUBSCRIBER
ALL INFORMATION IS REQUIRED TO COMPLETE ENROLLMENT, MAKE CHANGES, AND PROCESS CLAIMS
Group Legal Name: Group Number: Site Location / Cabinet: DHO Plan:
☐ NEW GROUP ENROLLMENT ☐ OPEN ENROLLMENT ☐ EVENT CHANGE ☐ COBRA (if applicable)
DATE(MM/DD/YY): COVERAGE ELECTION: EVENT:
☐ Employee On
ly ☐ New Hire ☐ Reduction of Hours Worked
Coverage Start Date: 01/01/2020
☐ Employee and Spouse/Partner ☐ Termination ☐ Divorced or Legal Separation
☐ Employee a
nd One Dependent ☐ Coverage Gained ☐ Over Age Limit
Coverage End Date:
☐ Employee and Dependents ☐ Coverage Lost ☐ No Longer Full Time Student
☐ Decline: I decline coverage for
myself & dependent(s)
☐ Employee and Family
(Spouse/Partner &Dependent(s)
☐ Death
☐ Marriage
☐ Birth / Adoption
EMPLOYEE
(Subscriber)
☐ Add
☐ Term
☐ Update
Social Security Number Employee Hire Date
Last Name First Name MI Birth Date
Home Address City State Zip
Contact Phone Number
Email ☐ Receive electronic EOB statements
SPOUSE /
PARTNER
☐ Add
☐ Term
☐ Update
Social Security Number Birth Date
Other Dental Coverage?
☐ Yes ☐ No
Is Other Policy Primary?
☐ Yes ☐ No
Last Name First Name MI
DEPENDENT
☐ Add
☐ Term
☐ Update
Social Security Number Birth Date
☐ Disability / Exception
☐ Full Time Student
Other Dental Coverage?
☐ Yes ☐ No
Is Other Policy Primary?
☐ Yes ☐ No
Last Name First Name MI
DEPENDENT
☐ Add
☐ Term
☐ Update
Social Security Number Birth Date
☐ Disability / Exception
☐ Full Time Student
Other Dental Coverage?
☐ Yes ☐ No
Is Other Policy Primary?
☐ Yes ☐ No
Last Name First Name MI
DEPENDENT
☐ Add
☐ Term
☐ Update
Social Security Number Birth Date
☐ Disability / Exception
☐ Full Time Student
Other Dental Coverage?
☐ Yes ☐ No
Is Other Policy Primary?
☐ Yes ☐ No
Last Name First Name MI
AUTHORIZATION AND ACKNOWLEDGMENT: I hereby declare that all the statements made above are, to the best of my knowledge and belief, true and
complete and that I understand they are the basis on which insurance requested by me may be issued. All statements made by me are representations
and not warranties. No statement made by me will be used to contest the insurance provided by the Policy, unless: 1) it is contained in a written statement
signed by me; and 2) a copy of the statement is furnished to me. I agree that a photocopy of this form shall be as valid as the original, and that it shall be
valid for 24 months from the date signed. I also understand that I, or the person authorized to act on my behalf, is entitled to receive a copy of this
authorization form. I understand that my nonpublic health information cannot be disclosed without my express, written permission. I understand that by
signing this form I am authorizing the necessary premium deductions from by salary or wages for the coverage I have selected.
For Indiana Residents: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or
misleading information commits a felony.
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.
Employee
Date
Employer Benefits Administrator/Authorized Agent
Date_______________________
Benefits Administrator signature not required if Subscriber application is submitted with Employer application or renewal. HRI_______________________
FORM:2015-08Rev
InsuringSmiles.com
POBox659EvansvilleIN47704‐0659
800727‐1444Fax:(812)424‐2096
Warrick County Government Rates
Employee Only - $26.60 per month
Employee + One - $56.20 per month
Employee + Family - $101.56 per month
Warrick County Government
