Get Employee Enrollment App With Liberty Dhmo (3).pdf

Filling out the Employee Enrollment Application for Liberty DHMO online is a straightforward process that requires attention to detail. This guide will walk you through each section of the form, ensuring you complete it correctly and efficiently.

Follow the steps to complete your enrollment application online.

1. Press the ‘Get Form’ button to access the application and open it in your preferred online editor.
2. Begin by entering your Dental Group number and Benefit number in the designated fields. Ensure accuracy to prevent any issues with your application.
3. Fill in the Company name and Division, followed by your Proposed Effective Date in MMDDYYYY format. Provide the Company city and State where applicable.
4. Complete your Employee Information section. Enter your Last name, First name, Middle Initial, Social Security number, Date of birth, Phone number, Gender, Email address, Street address, Apt/Suite/PO Box number, City, State, Zip code, County, preferred Language, and Employment status.
5. If you have dependents applying for coverage, provide their details. Complete the Dependent Information section for each dependent, including Last name, First name, Middle Initial, Social Security number, Date of birth, and Relationship. Specify if they are a Full-time student or Disabled, and, if applicable, indicate the Network name and Primary dentist.
6. Indicate your Coverage type by selecting the appropriate option, whether it be Employee only, Employee and spouse/domestic partner, Employee and child(ren), or Family. Also, answer questions regarding your previous dental coverage within the past 12 months.
7. For the waiver of coverage section, if applicable, acknowledge whether you are waiving coverage for yourself, spouse/domestic partner, or dependent child(ren). Provide a reason for declining the coverage.
8. Sign and date the form at the bottom where indicated, including the name and relationship of any legal representative if needed.
9. Once you have reviewed all entered information for accuracy, save your changes. You can download, print, or share your completed form as needed.

Complete your Employee Enrollment Application online today to ensure timely processing of your benefits.