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No Benefit Dental Vision AD&D First Name Last Name Mailing Address City State Zip Code Phone Text: Yes No Date of Birth (MM/DD/YYYY) Email Address SSN/Member ID# Marital Status Married Single Gender Male Female Effective Date (MM/DD/YY) Date of Hire (Required) (MM/DD/YY) Group Number Subgroup/Dept. # Employer’s Full Name Employer’s Address Authorization of Coverage Authorization Check here to waive if no coverage is desired Check here to waive if you have additional coverage through another policy I understand my information is protected by privacy laws and will be released only in accordance with these laws. The only people who have access to this information are employees of the Insurance Company who service my policy or claims and other third parties authorized by the Insurance Company. Information may be disclosed to those who have an insurance-related regulatory or legal need for the information. In other situations, We will ask you for written authorization to disclose information about you. WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. Fraud Warning for Kentucky Applicants: WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. I agree and understand that if my employer is contributing towards the cost of any of the insurance products I have chosen to decline, I will not be entitled to any compensation for my non-participation. Signature (Required) Date ACE USA is the U.S. domestic operating division of ACE Limited. Insurance products and services are provided by the U.S. insurance underwriting companies and not by ACE Limited. This plan of insurance is underwritten by ACE American Insurance Company. Must be completed in FULL – PLEASE PRINT – Enrollment is not valid without signature at the bottom of this page. AH-29594 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] www.dentalselect.com Employee Enrollment Form Individuals Covered - List individuals for whom you are enrolling and select plan option. Dental Vision AD&D Spouse Name - (Last, First, MI) Gender Male Female SSN Date of Birth - (MM/DD/YYYY) Dental Vision AD&D Dependent Name - (Last, First, MI) Gender Male Female SSN Date of Birth - (MM/DD/YYYY) Dental Vision AD&D Dependent Name - (Last, First, MI) Gender Male Female SSN Date of Birth - (MM/DD/YYYY) Dental Vision AD&D Dependent Name - (Last, First, MI) Gender Male Female SSN Date of Birth - (MM/DD/YYYY) Dental Vision AD&D Dependent Name - (Last, First, MI) Gender Male Female SSN Date of Birth - (MM/DD/YYYY) For additional dependents include the Dependent Enrollment Form Covered by other DENTAL Insurance? Yes No If Yes, Name of other Dental Insurance Company Name of Person Insured Social Security Number Coverage Selection - Confirm available options with your employer. Check all that apply. Dental Plan Discount - Silver Co-Pay - Gold Co-Pay - Platinum Co-Insurance PPO* - Gold Co-Insurance PPO/MAC - Platinum * Where permitted by law Co-Insurance Passive PPO/Indemnity - Platinum ACA EHB Child Only Other Dual Options - If applicable, select High or Low to indicate plan type, otherwise leave blank. High Low Vision Plan Vis 1 Vis 2 Vis 3 Vis 4 Vis 5 Vis 6 Vis 7 Vis 8 Vis 9 Vis 10 Vis 11 Other AD&D Plan Option - Utah & Texas Only Contributory - Amount Employee (Complete beneficiary info on Designation Form) Employee & Family (Complete individuals covered and sign page 2) Voluntary AD&D - Amount (Complete beneficiary info on Designation Form) Principal Sums range from $10,000 to $250,000. Refer to plan flyer for specifications. 2015 ENR.01.9000216 07/15 SIGN