WELFARE United Federation of Teachers FUND 52 Broadway New York New York 10004 212 539-0500 DENTAL ENROLLMENT/TRANSFER FORM I choose D UFT Welfare Fund Scheduled Benefit Plan D Dentcare HMO D UFT Florida Dental Discount Plan permanent Florida residents only. Plan o Only one dentist may be selected for the entire family. o Relationship arne include last name if different from your last name Birth Date Mo/DayNr Sex Provider Name and Code umber Must be completed if selecting Dentcare HMO Spouse Child Upon completion of the Enrollment/Transfer Form please sign and mail it to the UFT Welfare Fund at the address aboveAttention DENTAL ENROLLMENT. D Retiree D Pre- 70 Retiree D COBRA Social Security Number Last Name First Name Middle Initial City State Home Street Address Work Phone Zip Code Marital Status D Single D Married D Widowed Divorced Home Phone Must complete D Domestic Partner Spouse/Domestic Partner s SS / / Is spouse/domestic partner a UFT member DYes D 0 Are you covered for dental ....
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How to fill out the UFT Welfare Fund's Dental Enrollment/Transfer Form online
Filling out the UFT Welfare Fund's Dental Enrollment/Transfer Form online can streamline your enrollment process and ensure you have access to dental benefits. This guide provides clear, step-by-step instructions to help you navigate the form efficiently.
Follow the steps to complete your dental enrollment or transfer online.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Carefully review the form's introduction section, which outlines the purpose of the form and provides essential information about eligibility requirements.
- In the personal information section, fill in your full name, address, phone number, and email. Make sure to enter accurate and up-to-date information.
- In the dependent information section, provide the necessary details of any dependents you wish to enroll. Ensure that you include their full names, dates of birth, and relationship to you.
- Complete the coverage selection section by indicating your preferred dental plan. Review the plans offered to make an informed choice.
- In the authorization section, read the statements carefully and sign the form electronically to confirm your understanding and acceptance of the terms.
- Once you have filled out all required sections, review the form for accuracy to avoid any potential delays in processing.
- Finally, save your changes, and choose to download, print, or share the form as needed to complete your submission.
Begin the process of filling out your UFT Welfare Fund's Dental Enrollment/Transfer Form online today.
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