BEST Life and Health Insurance Company

Dental & Vision Enrollment / Change Form
Please fill out the following form.

Submission Type

Dental Dual Option

Vision Dual Option

Last Name *

Enter your last name

First Name *

Enter your first name

M.I.

Date of Birth *

Enter date of birth

Sex *

Select your gender

Age

Social Security Number *

Enter your SSN

Residence Street Address *

Enter your street address

City *

Enter your city

State *

Select your state

Zip *

Enter your zip code

Name of Company *

Enter your company name

Group #, If known

Division #

Job Title *

Enter your job title

Date of FT Employment *

Enter date of FT employment

Marital Status *

Select your marital status

If changing your name, provide new name:

Do you have eligible dependent children?

If So, How Many?

Will this replace other dental insurance?

Name of Carrier

Type

Policy # of Prior Coverage

Effective Date of Prior Coverage

Anticipated Termination Date of Prior Coverage

Dependent Information

Please fill out the following form.

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. Coverage can be extended for dependent children residing: FL and NE through age 29; and OH through age 27. For FL, NE and OH residents only: if enrolling dependent children 26 and older, please indicate if they are a full-time student. Part-time students allowed in FL. All other residents can leave this column blank.

Qualifying Event

Dependent Name

Relation

Full-Time Student?

Sex

Social Security Number

Date of Birth

Qualifying Event

Dependent Name

Relation

Full-Time Student?

Sex

Social Security Number

Date of Birth

Qualifying Event

Dependent Name

Relation

Full-Time Student?

Sex

Social Security Number

Date of Birth

Qualifying Event

Dependent Name

Relation

Full-Time Student?

Sex

Social Security Number

Date of Birth

Qualifying Event

Dependent Name

Relation

Full-Time Student?

Sex

Social Security Number

Date of Birth

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:
	Myself and Any Dependents
	Spouse Only
	Child(ren) Only
	Spouse and Dependent Child(ren)

I waive Vision coverage for:
	Myself and Any Dependents
	Spouse Only
	Child(ren) Only
	Spouse and Dependent Child(ren)

Reason For Waiving Coverage You must provide a reason for waiving coverage
	Other Coverage
	Cost

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. I understand that if I desire to apply for vision insurance for myself and dependents at a later date under the beneficial Employees Security Trust, I/we will be eligible for no more than a total of $75 of vision benefits during the first 12 months of 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 completion of this form? *

Please select an item.

If Yes, Please Provide that Person's Name

Email for Confirmation *

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Check for authorization

EMPLOYEE'S AUTHORIZATION *

You accept all terms above and certify that all information supplied above is correct.

Enter Security Code Shown Above:

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