GME Division of Medical Education
Graduate
Medical Education

COBRA Standard Dental Enrollment Form

STANDARD INSURANCE COMPANY MEMBERSHIP AND CHANGE FORM
1. GROUP POLICY NO
 2. EFFECTIVE DATE OF COVERAGE OR CHANGE
/ / 		3. EMPLOYER/GROUP NAME
DIVISION ID
 CLASS
 4. JOB TITLE/ OCCUPATION
 4a. SALARY
HR MO
WK YR
5. YOUR NAME - Last, First Middle
 6. SOCIAL SECURITY #
 7. SEX
M F
8. YOUR ADDRESS
 9. CITY
 12. STATE
 11. ZIP
12. DATE OF BIRTH
/ / 		13. HAVE YOU HAD DENTAL INSURANCE WITH STANDARD DENTAL BEFORE? YES NO
IF YES, LAST TERMINATION DATE / / 		14. DATE OF FULL TIME EMPLOYMENT
/ /
15. MARITAL STATUS single married divorced separated widowed
16. Family members to be Covered or Deleted under this plan:
List dependents to enroll or delete SEX DATE OF BIRTH List dependents to enroll or delete SEX DATE OF BIRTH
SPOUSE
M
F
 / / CHILD 3
M
F
 / /
CHILD 1
M
F
 / / CHILD 4
M
F
 / /
CHILD 2
M
F
 / / CHILD 5
M
F
 / /
17. Is your spouse Yes No or child(ren) Yes No enrolled in another dental plan?
If yes, employer name Insurance Co.
18. Are you enrolled in your spouse's Dental Plan? Yes No
19. Do you have children under the age of 19? Yes No
20. Do you have unmarried children age 19 to 25 who are full-time students dependent on you? Yes No
21. Dental coverage will apply to:
A Employee, Spouse and Children
B Employee and spouse
C Employee only
D Employee and children (no spouse)		 22. I am applying:
To add dependents (complete spaces 1, 3, 5, 6, and 8-24)
To delete depndents (complete spaces 1, 3, 5, 6, and 8-24)
To change address (complete spacs 1, 3, 5, 6, 8-11 and 23-24)
To change name (complete spaces 1, 3, 5, 6, 15, and 23-24)
Married within last 31 days? If yes, Date: / / (complete spaces 1, 3, 5, 6, 15, and 23-24)
COBRA Effective date / /
Due to loss of coverage, Effective Date: / /
Authorize payroll deduction where applicable
23. YOUR SIGNATURE (IN INK)
 24. DATE
DENTAL INSURANCE WAIVER
CONTRIBUTORY DENTAL INSURANCE DECLINED BY EMPLOYEE AND/OR DEPENDENTS
The Group Dental Insurance Coverage available to me and my Dependents has been explained to me and I don't want to enroll. I understand that if I change my mind later, the Dental Insurance Coverage I am now waiving will be subject to a Late Enrollment Penalty.
I decline Group Dental Insurance for myself (employee).
I decline Group Dental Insurance for one or more of my dependents
I am currently covered under another plan. Name of Carrier
23. YOUR SIGNATURE (IN INK)
 24. DATE

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