Get Eligibility Enrollment Change Form - Delta Dental Of New Jersey

Filling out the Eligibility Enrollment Change Form online can be a straightforward process when guided correctly. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access and open the Eligibility Enrollment Change Form in your preferred editor.
2. Begin by completing the Employer Group Information section. This includes filling out the Group Name and Group Number clearly, along with any applicable sublocation or store location details.
3. In Section A, indicate the Type of Activity. Check the appropriate boxes for enrollment, adding or removing dependents, and provide effective dates as required. Be sure to follow the instructions on the back of the form for clarity.
4. Move to Section B, where you will input your Employee Information. Fill in your last name, first name, middle initial, social security number, home telephone, email address, home address, employer name, work telephone, and work address.
5. In Section C, select the Plan Option offered by your employer by checking one of the available options, such as Delta Dental Premier® or Delta Dental PPO.
6. Section D requires you to provide details about the individuals covered under your plan. Specify if you are adding, changing, or removing coverage for dependents using the designated codes (A for add, C for change, R for remove). Include their names, sex, birth date, and social security numbers.
7. Continue to Section E, where you can disclose any existing health coverage for yourself or your dependents, if applicable.
8. In Section F, provide any additional dependent information, noting if any dependents live at different addresses and explaining any name discrepancies.
9. Section G requires your signature to affirm that all information is accurate and complete. This signature is necessary for processing the form.
10. Lastly, ensure that the Employer completes Section H. They must sign and date this section for the enrollment or change to be processed.
11. Review all sections for accuracy, save your completed form, and proceed to download, print, or share it as needed.

Complete your Eligibility Enrollment Change Form online today to ensure your coverage needs are met without delay.