Dental Enrollment/Change Form (CA)

* Denotes a required field

Dual Option:

EMPLOYEE INFORMATION
Last name * First name * M.I.
Date of birth * Age
Sex *

Social security number *
Residence street address *
City *
State *
Zip *
Name of company *
Group #, if known

Job title *
Marital status *
If changing your name, provide new name
Do you have any eligible dependent children?       If yes, how many?
Will this replace other dental insurance?       Name of Carrier
Policy # Effective Date
Anticipated Termination Date of Prior Coverage
DEPENDENT INFORMATION
California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.

Are you insuring your dependent? *
If ‘Yes’, complete the section below and explain any differences in last name, if applicable. If no, complete the waiver of coverage section, below.

Eligible dependents include spouses and unmarried dependent children. Dependent children are covered through age 25.
Qualifying Event (Select One) Dependent Name Relation Full-Time Student? Sex SSN Date of Birth
:
Spouse














WAIVER OF COVERAGE

Complete if you or any of your eligible dependents are declining or refusing any type of offered coverage. Check all that apply:

I waive Dental coverage for:

Reason for waiving coverage (you must provide a reason for waiving coverage): Other coverage

I understand that if I desire to apply for dental insurance for myself and dependents at a later date, outside of open enrollment and any qualifying events, under the Beneficial Employees Security Trust, I/we will be eligible for Class I, Preventive Procedures during the first 12 months of continuous coverage and during the second 12 months of continuous coverage, eligible for Class I, Preventive Procedures and for 50% of the benefits for Class II Basic Procedures not to exceed a maximum of $500 during the second 12 months of continuous coverage.

SIGNATURE REQUIRED BELOW


I certify that my date of birth, date of employment and other information on this form are correct and that I am working at the employer’s place of business in full time employment at least 30 hours per week. I authorize my employer to make deductions from my earnings necessary to provide my contribution for this coverage and understand that my employer is performing this service for my benefit and not as an agent of the insurer. I understand that coverage is not in force until the effective date shown on the Certificate of Insurance issued to me; however, if I am absent from full-time employment on such dates as the result of an accident or sickness, I agree that coverage is not effective. I determine the coverage in force and that coverage is not in force if an application for that coverage has not been made by my employer. Additionally, if I am accepted, this request for group insurance will become part of the agreement between BEST Life and Health Insurance Company and myself. I, and any enrolled family members, agree to be bound by the arbitration clause in the BEST Life and Health Insurance Certificate Booklet, if any, instead of trial by a court of jury. I agree that insurance does not begin until this application is approved by BEST Life and Health Insurance Company, my insurance certificate is issued, and the first premium is paid.

Fraud Notice - The following general Fraud Notice is intended to comply with the laws of your state. If any part of such language is found in conflict, such language shall be construed as amended to the extent necessary in order to meet the minimum requirements of your state. Any person who, knowingly and with intent to defraud or deceive any insurance company, files an application containing any materially false, incomplete or misleading information may be guilty of committing a fraudulent insurance act which is a crime and may be subject to criminal prosecution.

Has any person assisted you in the completing of this form? *
If Yes, please provide that person's name:

A value is required.

Please check for authorization.EMPLOYEE'S AUTHORIZATION * (YOU ACCEPT ALL TERMS ABOVE AND CERTIFY THAT ALL INFORMATION SUPPLIED ABOVE IS CORRECT)

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