Delta Dental Individual and Family SM
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- Gwendoline Sherman
- 5 years ago
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1 Delta Dental Individual and Family SM ENROLLMENT FORM The effective date of your individual dental plan will be the first of the month following receipt of this completed enrollment form and payment, so long as both are received on or before the 25th of this month. If your form is received after the 25th of this month, your plan will be effective the first of the next month. Your effective date of coverage will be identified on your enrollment materials. SUBSCRIBER INFORMATION Please complete the information below. You must be at least 18 years of age and a Kansas resident to enroll. Last Name: Address: City:, Kansas ZIP: Social Security No.: Male Phone: Female First Name: Date of Birth: Please check the plan you wish to enroll in: Platinum Plan Gold Plan Silver Plan Bronze Plan Please check the type of coverage you are applying for: Individual Individual +1 Family COVERED DEPENDENTS List all covered dependents you are enrolling. If additional space is required, attach a list to this form. (Unmarried dependent children are covered through the end of the month in which they turn 26.) Last Name First Name Social Security No. Date of Birth (mm/dd/yyyy) Spouse M F Dependent M F Dependent M F Dependent M F Dependent M F Check here if you have been covered under a dental insurance plan within the last 60 days. Policy Name: Policy Number: Termination Date: Gender PAYMENT METHOD If you enroll using this paper application, you must submit a check or money order for one year of coverage. Make check payable to Delta Dental of Kansas. If you prefer to pay automatically each month from a credit/debit card or checking account withdrawal, you may enroll online at DeltaDentalKS.com. Individual* Individual +1* Family* Platinum Gold Silver Bronze Monthly Yearly Monthly Yearly Monthly Yearly Monthly Yearly $68.62 $ $45.32 $ $37.80 $ $ $1, $87.49 $1, $73.20 $ $ $2, $ $1, $ $1, $32.59 $ $65.14 $ $92.82 $1, *Delta Dental of Kansas reserves the right to change rates upon the rates being placed on file by the Kansas Insurance Department. Visit DeltaDentalKS.com or call to confirm current rates. DDIP1-001 (8/24/2016) Please also complete the back side of this form.
2 Please be sure you have completed the front side of this form. Please carefully read the terms of the Subscription Agreement to Provide Dental Benefits incorporated herein by reference, and review the information provided in this application before signing below. Your signature is required to complete enrollment. Agreement Approval I represent that I am over the age of 18, a legal resident of Kansas and am legally authorized to apply for coverage for myself and for all other persons named in this application. I understand that I am making an application for dental coverage offered by Delta Dental of Kansas (DDKS). I understand that I am responsible to pay premium charges to DDKS for this coverage, and if payment is not made when due, my coverage is subject to termination. I understand that coverage for the dental care policy applied for will not start until after this application and the required monies for premium are received and accepted by DDKS and an effective date is established by DDKS. All complete applications received and processed by DDKS on or before the 25th of the month will be effective the first of the concurrent month (e.g., a January 25th application is effective on February 1st; a January 26th application is effective on March 1st). Rates are guaranteed for 12 months from the date of first eligibility (e.g., rates for individual plans effective April 1st are guaranteed until March 31st of the following year). I understand that written notice of rate changes will be furnished by DDKS at least sixty (60) days prior to the effective date of any such rate change. I represent that prior to completing this application, I carefully and fully read it and the Subscription Agreement incorporated herein. I represent that the statements and answers set forth are full, true, and correct, to the best of my knowledge and belief, and that no information required to be given, either expressly or by implication, has been knowingly withheld. I understand that DDKS will rely upon the completeness and truthfulness of the information given and the statements made, and that if I have made any false statements or misrepresentations, or have failed to disclose or have concealed any material fact, DDKS will be entitled to declare the dental care policy applied for void and refuse allowance of benefits to any person thereunder. Refunds will be issued for any month in which a payment was received by DDKS, but due to the termination of the Subscription Agreement or loss of coverage as set forth in Section 2 therein, the Enrollee was not entitled to benefits during that month. I authorize any health care provider to release medical records to DDKS when reasonably related to the dental care coverage for which I have applied. If any law or regulation requires additional authorization for release of dental records, I will give this authorization. To cancel coverage, DDKS requires at least a thirty (30)-day written notice prior to the requested termination date. I further agree to be legally bound by the terms contained herein and the terms contained in the Subscription Agreement incorporated herein. Enrollee Signature: Date: Mail to: Delta Dental of Kansas PO Box 3806 Wichita, KS Broker / Agent Code: (if applicable) for internal use only mailed on: effective date: DDIP1-001 (8/24/2016)
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21 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). သတ ပ ရန - အကယ သင သည မန မ စက က ပ ပ က ဘ သ စက အက အည အခမ သင အတတက စ စဥ ဆ င င က ပ ပ မည ဖ န န ပ တ (TTY: ) သ ႔ ခၚဆ ပ ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: ). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ).. توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با ( (TTY: تماس بگیرید. KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu (TTY: ).
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