Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other _________________________

Availability of coverage is determined by your employer and whether the coverage is approved for issuance by the insurer(s).

Please list the insurer(s) below from whom you are applying for coverage and check all benefits for which you are applying.

If you have been given a choice of plans to apply for, or if the coverage you are applying for requires the selection of a primary care provider/clinic/network, please complete the section entitled “Provider and/or Product Selection.”

If you are waiving application for any coverage on yourself and/or your spouse and/or dependent child(ren), please complete the “Waiver of Coverage” section at the end of this section.

[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)

[ ] Employee, Spouse and Dependent Child(ren)

Insurer: _________________________________________ Insurer: ________________________________________

Within the past 12 months, have you, your spouse or your dependent child(ren) had any individual or other group dental coverage? [ ] Yes [ ] No

If “Yes,” please provide the following information:

Orthodontia coverage? [ ] Yes [ ] No

Dental Insurer Name: _______________________________ Policy Number: ____________________

Address: __________________________________________ Phone Number: ____________________

Coverage Effective Date: __________________ Termination Date: ____________________

Is coverage still in effect? [ ] Yes [ ] No

Who was or is covered under the policy listed above? _____________________________________________________

Please attach copies of Certificates of Prior Coverage.

Insurer: __________________________________________ Insurer: __________________________________________

Employee Life/AD&D Amounts: Basic Issue $__________ Supplemental $__________ Optional $__________

Primary Beneficiary Name ________________________________ Beneficiary’s Social Security ___________________

Relationship of Beneficiary _____________________

Secondary Beneficiary Name ______________________________ Beneficiary’s Social Security ___________________

Relationship of Beneficiary _____________________