HomeMy WebLinkAbout2025 Delta DentalENROLLMENT/CHANGE FORM - CA
Delta Dental of California
Primary Enrollee Information
Social Security Number Enrollee ID Number (if applicable)Date of Birth
/ /
Marital Status
Single Married
Gender
Male Female
First Name
Mailing Address (Street)
E-mail Address (internal use only)
Employee Classification
Group No.
/ /Effective
Date
Division
Name of Employer
FOR GROUP USE ONLY
City State Zip Code
*If a dependent is enrolling under his/her social
security number, the SSN currently enrolled
under must be provided.
Termination
Reduction in Hours
Divorce/Legal Separation*
Widowed/Surviving Dependent*
Dependent Child No Longer Eligible*
COBRA (if applicable)
Indicate qualifying date: _____________________
/ /Hire
Date
State
Phone TypePhone Number( ) -
Relationship
Spouse/Partner
Dependent
Dependent
Dependent
Dependent
Name of School (overage student)**
Please attach a separate sheet for additional dependent information. All dependents listed will be considered enrolled. **Additional documentation will be required for disabled and student status.
Enrollee Classification
Dependent Information
VERY IMPORTANT - Please Print Legibly
Marital Status Change
Address Change
New Enrollment
Add/Delete Dependent
SSN/Enrollee ID Number Correction or
previous ID under which benefits are received
Terminate Enrollee Coverage
Other __________________
/ /
Last Name Middle Initial
Form 3400 CA
DateSignature of Enrollee
I authorize any payroll deduction that may be required towards the cost of this coverage. I certify that the above information is true and correct to the best of my
knowledge. I understand that changes can only be made if I experience a qualifying family status change, in which case the change must be consistent with that
event, or as may otherwise be provided by the group contract.
/ /
1-11
Dependent First Name (Last only if different from enrollee)
Add / Term Social Security Number
/ /
Date of Birth Male / Female Student / Disabled**
/ /
/ /
/ /
/ /
Enrollee/Change Information
I decline coverage at this time.
Pay Code Benefit Package
Cell Work Home
Location
Delta Dental of California
P.O. Box 429086
San Francisco, CA 94142-9086
deltadentalins.com
State Zip CodeCityEffective Date
of Other Policy / /
Date of Birth
/ /
Name of Other Dental Carrier Policy Holder Name (first/last)
Policy Holder Street Address
Full-Time
Part-Time
Retired
Hourly
Salaried
Member/Other _______________
Certified
Classified