Direct Reimbursement Dental Plan Addition/Termination/Change (ATC) Form
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Name of Company:
Name of Employee:
Address Line 1:
Address Line 2:
City:
State:
Select a State
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District of Columbia
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Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Add Spouse/Partner
(Check box if you wish to add your spouse/partner)
Effective from:
(mm/dd/yyyy)
Reason for addition :
Newly married
Open enrollment
Other
Please specify
Spouses name:
Sex:
Male
/ Female
Social Security Number:
Date of Birth:
(mm/dd/yyyy)
Add Dependent
(Check box if you wish to add dependent(s))
Date effective from:
(mm/dd/yyyy)
Reason for addition :
Newborn
Open enrollment
Other
Please Specify
Dependent's Name:
Sex:
Male
/ Female
Social Security Number:
Date of Birth:
(mm/dd/yyyy)
Terminate coverage
(Check box if you wish to terminate an individual's cover)
Terminate coverage for:
Employee
Spouse/Partner only
Dependant(s) only
Spouse and dependants only
Family
Last date of coverage:
(mm/dd/yyyy)
Reason for termination:
Left employer
Switched to another plan
Discontinue Cobra
Other
Please Specify
Change
(Check box if you wish to change details)
Effective date of change:
Name of member for whom
change is being made:
New name:
Address:
Telephone (work):
Change to Cobra
(Check box if you wish to change Cobra details)
Change to be effected:
Employee
Employee and spouse
Employee and dependent(s)
Spouse only
Dependent(s) only
Family
Partner only
Qualifying event:
Date of qualifying event
(mm/dd/yyyy)
Date of Cobra effective:
(mm/dd/yyyy)
Other amendments
(Check box if you wish to make another amendment)
Amendment:
Reason:
Authorization
Employer Authorization:
By checking this box
, I authorize this form to be actioned.
Name of person filing this form:
Authorization date:
(mm/dd/yyyy)