Get Enrollment Form - Delta State University - Deltastate

Filling out the Enrollment Form for Delta State University is an important step for securing dental coverage. This guide offers clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the enrollment form seamlessly.

1. Click ‘Get Form’ button to retrieve the enrollment form and access it in your preferred format.
2. Begin by selecting the appropriate division for your plan—High or Low. Ensure to check the correct box for your selection.
3. Provide your primary enrollee information, including your full name. Ensure each word is legible and separated by a blank box.
4. Input your mailing address accurately, completing all fields such as street address, city, state, and zip code.
5. Fill in your social security number and date of birth. Be sure to include your marital status and details about dependents, if applicable.
6. Indicate if you have dependent children and whether you or your dependents are covered under another dental plan.
7. List any eligible dependents who will be covered, along with their names and dates of birth. If additional space is needed, attach a separate sheet.
8. Sign and date the form to authorize any necessary payroll deductions and confirm the accuracy of the provided information.
9. Once all sections are filled out, you may save your changes, download, print, or share the completed form as necessary.

Start filling out your Enrollment Form online today to secure your dental coverage.