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:
City:
State:
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
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
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