Get Hi Dental Service App 01a 2019-2026

The HI Dental Service APP 01A is essential for employers seeking dental coverage for their staff. This guide provides clear instructions to help you successfully complete the application online.

Follow the steps to fill out the HI Dental Service APP 01A with ease.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by selecting your desired dental plan from the available options, such as HDS Preventive or HDS Premium Plus.
3. Provide your group information, including the desired start date, full legal name of the group, Federal Identification Number (FIN), and DOL Unemployment Insurance ID#.
4. Indicate your type of business and the current dental and medical carriers, if applicable.
5. Input the total number of W-2 employees along with the number of benefit-eligible employees and those enrolling in the plan.
6. Check all applicable categories of members eligible for coverage, including full-time and part-time employees, dependents, and retirees.
7. Specify the employer contribution details and any conditions associated with the dental plan offering.
8. Complete the COBRA section, indicating whether COBRA will be offered and if HDS will collect COBRA premiums directly.
9. Fill out the contact information for the group administrator, ensuring to include their title, telephone number, and email address.
10. If applicable, answer the broker section questions and provide the necessary broker information.
11. Review the acknowledgment section and confirm that all provided information is true and complete.
12. Sign and date the application in the designated approval section.
13. Once you have filled out all required information, you can save changes, download, print, or share the completed form as needed.

Complete your HI Dental Service APP 01A online today for streamlined dental coverage.