Get Dual Choice Enrollment/change Form - Delta Dental Ins

Filling out the DUAL CHOICE ENROLLMENT/CHANGE FORM for Delta Dental Insurance can be straightforward with the right guidance. This user-friendly guide will walk you through each section of the form, ensuring you provide the necessary information accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in your chosen editing tool.
2. Select the appropriate program by checking the corresponding box at the top of the form. You will also need to provide the effective date for your enrollment or change.
3. Fill out the primary enrollee information section legibly. Ensure to print your name, mailing address, and date of birth, leaving one blank box between each word.
4. Indicate your group number and sublocation if applicable. Choose the correct status from options like New Hire, Open Enrollment, COBRA, and write in the name of your employer or group.
5. Select your marital status by checking either Single or Married and indicate the date of your full-time hire. Include your phone number for contact purposes.
6. Respond to questions regarding dependents. Indicate whether you have dependent children, and if so, list them in the dedicated section provided on the form. Remember to attach a separate sheet if you have additional dependents.
7. Complete the COBRA enrollment section, if applicable, by indicating the qualifying event and the date it occurred.
8. In the dentist section, fill in your preferred dentist's name, provider number, and the state of the provider.
9. At the end of the form, authorize the payroll deductions required for coverage and confirm that the information provided is accurate. Sign and date the form.
10. Finally, save your changes to the completed form. You can choose to download, print, or share the document as needed.

Start completing your DUAL CHOICE ENROLLMENT/CHANGE FORM online today!