Direct Reimbursement Dental Plan Enrollment Form
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SECTION I : General Information
Name of Company:
Coverage Elected: Employee   Employee & Spouse   Employee & Child   Family
Name of Employee:
Date of Birth: (mm/dd/yyyy)
Address Line 1:
Address Line 2:
Social Security Number:
Home Phone:

SECTION 2 : Complete this section only if you are electing dependent coverage
Spouse's Name:
Date of Birth: (mm/dd/yyyy)

Dependent Children* - please enter details for each child in the boxes below. In the name box enter each child's name followed by a comma and a carriage return (enter key). Likewise for Date of Birth and Relationship

*Dependent Children between the ages of 19 and 23 must be unmarried and full-time students.

Child's Name: Date of Birth: Relationship:

Employer must complete
Date of Hire: Effective Date of Coverage: Late Applicant?: Yes    No