This certification; that the employees named herein is eligible for enrollment in the State Dental Insurance Program. @ 21. TELEPHONE NUMBER (Include Area Code) 23. EMAIL ADDRESS Distribute one copy each to Controller, Carrier, Agency, and Employee 22. DATE RECEIVED IN EMPLOYING OFFICE Month Day Year STATE OF CALIFORNIA - CALIFORNIA DEPARTMENT OF HUMAN RESOURCES DENTAL PLAN ENROLLMENT AUTHORIZATION STD. 692 (REV. 3/2015)(REVERSE) PRIVACY NOTICE The Information Practices Act of 1977 (C.
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How to fill out the CA STD. 692 online
The CA STD. 692 form, known as the Dental Plan Enrollment Authorization, is essential for users wishing to enroll in, change, or cancel their dental plan coverage. This guide provides step-by-step instructions tailored to help you complete the form accurately and efficiently online.
Follow the steps to successfully complete the CA STD. 692 online.
- Click the ‘Get Form’ button to acquire the form and access it in the editor.
- In Section A, indicate the type of action you are taking: new enrollment, cancellation, change, or COBRA enrollment. Ensure you complete the relevant sections accordingly.
- In Section B, provide your personal details including your full name, date of birth, gender, marital status, social security number, and the name of the dental plan you are enrolling in or changing.
- If you are changing family member enrollment, list all enrolled family members and denote whom you are adding or deleting. Use the action codes A for add and D for delete.
- In Section C, if your prior dental plan differs, specify the name of that plan. This is required for plan changes and cancellations.
- Section D requires your signature and date, confirming your authorization for deductions from your salary for the dental plan selected. You also need to certify the eligibility of listed family members.
- Finally, review all sections for accuracy. You can save your changes, download or print the completed form as needed, and ensure it is sent to your personnel or payroll office.
Complete your CA STD. 692 form online now for seamless dental plan enrollment.
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