Individual Delta Dental Enrollment Form

ENROLLMENT/CHANGE OF STATUS/WAIVER FORM
PLEASE KEEP A COPY FOR YOUR FILES. Please note that completing this form does not guarantee coverage.
ALL GROUPS MUST COMPLETE THIS SECTION Note: Incomplete forms will be returned.
Delta Dental Group Number _______________ Sublocation Number_____________ w Salaried w Hourly
Effective Date _________________________ Date of Hire_____________________ OR Date of Rehire ___________ w Non-Union w Union
Name of Employer ____________________________________________________ Location/Department _________ w Other________________

Group Contact____________________________________________________________________________________________________________
Group Contact Phone _________________________________ Group Contact Email ___________________________________________________
EMPLOYEE / DEPENDENT / ADDITIONS / TERMINATIONS / CHANGES

Please check one of the options below:
w Yes, I want to enroll in the dental plan offered by Delta Dental of Illinois. (Please select a network below.)
w Delta Dental PPO/Delta Dental Premier If applicable: w High Option w Low Option
w DeltaCare DHMO (please complete the section below)
Dentist Name _________________________________________ Address ___________________________________ Facility Code _______
w DeltaCare DHMO Dentist Change (please complete the section below)
Dentist Name _________________________________________ Address ___________________________________ Facility Code _______
w No, I do not want to enroll in the dental plan offered by Delta Dental of Illinois. (If you are declining, please write your name below and sign at the bottom of this form.)
Social Security Number ______________________________ Employee’s Name ______________________________________________________
First Name MI Last Name
Alternate ID # ______________________________________ # Hours Worked ________ Job Title________________________________________

Mailing Address __________________________________________________________________________________________________________
Street City State Zip
Email Address __________________________________________________ Phone Number ____________________________________________

Marital Status: wS wM w Other Date of Birth _____/_____/_____ w Male w Female
REASON FOR SUBMITTING THIS FORM

w Initial or Open Enrollment w COBRA COBRA End Date ____/____/____ w Retiree
w Reinstatement due to: u Rehire u Loss of Other Coverage u Other __________________________________________
w Add Dependent (list below) due to:

u Birth u Adoption u Marriage u Loss of Other Coverage u Legal Guardianship u Disabled Dependent
u Military Dependent u Other ___________________________ Date of Qualifying Event ____/____/____
w Drop Dependent (list below) due to:
u Age u Death u Divorce u Other Coverage Elsewhere Date of Qualifying Event ____/____/____
w Termination of Employment Date ____/____/____ w Covered Under Spouse Date ____/____/____
w Name Change (Former Name ________________________________________________) w Address Change
COVERAGE DESIRED
w Employee Only w Employee & Spouse w Employee & One Child w Employee & Children w Entire Family
Is spouse covered under another dental plan? w Yes w No Other Carrier Name _________________________________________________
Are dependents covered by spouse’s plan? w Yes w No Spouse’s Carrier ____________________________________________________
Spouse’s Employer __________________________________________________
PLEASE LIST ALL ELIGIBLE DEPENDENTS TO BE COVERED

ADD DELETE FIRST NAME LAST NAME (if different) BIRTH DATE (mm/mm/yyyy) SEX (M or F)
w w 1. Spouse:
w w 2. Child:
w w 3.
w w 4.
w w 5.
I agree to continue membership in this program until the next open enrollment period and authorize payroll deduction where applicable.
Signature of Applicant ______________________________________________________________________________________________________
Mail to: Eligibility Department • P.O. Box 3384 • Lisle, IL 60532 • Fax (630) 369-0384 • Email eligibility@deltadentalil.com
DEL7014516 (6/10) DEN EE (6/10)

Individual Delta Dental Enrollment Form

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ENROLLMENT/CHANGE OF STATUS/WAIVER FORM

Name of Employer ________________________________________________ Location/Department _ w Other____________

EMPLOYEE / DEPENDENT / ADDITIONS / TERMINATIONS / CHANGES

Alternate ID # # Hours Worked Job Title__

Email Address ______ Phone Number

REASON FOR SUBMITTING THIS FORM

w Reinstatement due to: u Rehire u Loss of Other Coverage u Other __________________________________________

w Add Dependent (list below) due to:

PLEASE LIST ALL ELIGIBLE DEPENDENTS TO BE COVERED

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