Get Healtplex F-2206 2011-2024

Dental Plan Enrollment Form FOR DENTAL PLANS BY DENTCARE DELIVERY SYSTEMS INC. INTERNATIONAL HEALTHCARE SERVICES INC. HEALTHPLEX INSURANCE COMPANY OR HEALTHPLEX INC. Employee Information Last Name First Name M. I. Address City Home Phone State Work Phone Group Number Employer Name/Group Other Dental Coverage NO SSN/ID Number Zip Code Gender D. Dental Plan Enrollment Form FOR DENTAL PLANS BY DENTCARE DELIVERY SYSTEMS INC. INTERNATIONAL HEALTHCARE SERVICES INC. HEALTHPLEX INSURANCE COMPANY OR HEALTHPLEX INC. Employee Information Last Name First Name M. I. Address City Home Phone State Work Phone Group Number Employer Name/Group Other Dental Coverage NO SSN/ID Number Zip Code Gender D. O. B. Effective Date Date of Hire Name of Other Plan if applicable YES Group Plan Selection CapDent New York CapDent Plus New York CapDent Plus Ultra Preferred Choice Plan CapDent Select Healthplex Insurance Company Plan CapDent New Jersey Primary Coverage Selected Two Party EPO Comprehensive Voluntary Low Option Medium Option High Option High Enhanced Option Dental Selection Dentist Name Single Omni PPO Dentist Site Code Family For Managed Care Plans - Please choose one Primary Care Dentist from the CapDent Directory - One Per Family Dependents To Be Covered Spouse Domestic Partner unmarried dependent children If your child is over the age of 18 you must submit student documentation* Last Name First Name M/F Spouse/D. P. Son Dtr There is an additional monthly premium of 10. 00 for each family member in excess of five 5. Signature Date Broker Information Broker Name SSN/Tax ID Any person who includes any false or misleading information on an application for an Insurance Policy is subject to criminal and civil penalties. 333 Earle Ovington Blvd. Suite 300 Uniondale New York 11553-3608 www. healthplex. com P 800-468-0608 F 516-227-0582 F-2206 Print Date 3-4-2011 PLEASE PRINT OR TYPE ALL INFORMATION. HEALTHPLEX INSURANCE COMPANY OR HEALTHPLEX INC. Employee Information Last Name First Name M. I. Address City Home Phone State Work Phone Group Number Employer Name/Group Other Dental Coverage NO SSN/ID Number Zip Code Gender D. O. B. Effective Date Date of Hire Name of Other Plan if applicable YES Group Plan Selection CapDent New York CapDent Plus New York CapDent Plus Ultra Preferred Choice Plan CapDent Select Healthplex Insurance Company Plan CapDent New Jersey Primary Coverage Selected Two Party EPO Comprehensive Voluntary Low Option Medium Option High Option High Enhanced Option Dental Selection Dentist Name Single Omni PPO Dentist Site Code Family For Managed Care Plans - Please choose one Primary Care Dentist from the CapDent Directory - One Per Family Dependents To Be Covered Spouse Domestic Partner unmarried dependent children If your child is over the age of 18 you must submit student documentation* Last Name First Name M/F Spouse/D. O. B. Effective Date Date of Hire Name of Other Plan if applicable YES Group Plan Selection CapDent New York CapDent Plus New York CapDent Plus Ultra Preferred Choice Plan CapDent Select Healthplex Insurance Company Plan CapDent New Jersey Primary Coverage Selected Two Party EPO Comprehensive Voluntary Low Option Medium Option High Option High Enhanced Option Dental Selection Dentist Name Single Omni PPO Dentist Site Code Family For Managed Care Plans - Please choose one Primary Care Dentist from the CapDent Directory - One Per Family Dependents To Be Covered Spouse Domestic Partner unmarried dependent children If your child is over the age of 18 you must submit student documentation* Last Name First Name M/F Spouse/D. P. Son Dtr There is an additional monthly premium of 10. 00 for each family member in excess of five 5. .