Follow the steps to successfully complete your application.

1. Click the 'Get Form' button to obtain the form and access it in the editor.
2. Begin with Section 1: Employee Information. Provide essential details such as your group name, group number, division/store location, and your personal information, including your first and last name, social security number, sex, date of birth, and marital status.
3. In Section 2: Spouse and Dependent Information, list any spouses or dependents you wish to enroll or cancel. Include their full names, relationships, dates of birth, and check whether you want to enroll or cancel their coverage.
4. Proceed to Section 3: Coordination of Benefits. Answer the questions related to any other group dental coverage that your spouse or dependents may have. Providing accurate information is crucial for managing coverage effectively.
5. In Section 4: Change of Coverage, specify any coverage changes you wish to make, such as additions or cancellations. Fill out the name change information if applicable and provide reasons for your requested changes.
6. Complete Section 5: Employee Authorization. Read the authorization statement carefully, sign your name, and date the application. Your signature is essential for processing your request.
7. Once you have completed all sections, save your changes. You can choose to download, print, or share the form as needed to ensure timely submission.

Take action now by completing your MO Delta Dental Benefits Enrollment/Change Application online.