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ENROLLMENT FORM Altus Dental Insurance Company, Inc. PO Box 1557 Providence, RI 02901-1557 [PHONE REDACTED] GROUP INFORMATION To be completed by Human Resources or Benefit Administrator. Employer / Group Name Group No. Dental Division No. Date of Hire Location No. (if applicable) II. ENROLLMENT INFORMATION Effective Date of Action (MM/DD/YYYY) TYPE OF COVERAGE Dental QUALIFYING EVENT Open Enrollment New Hire/Re-hire Marriage Divorce Birth or Adoption Workers’ Compensation Return from Leave of Absence Loss of Coverage Full-Time/Part-Time Status Death of a Member ACTION CODE Check one. ADDITIONS New Subscriber Add Dependent to Family Reinstatement TERMINATION Remove Subscriber Remove Dependent List name in Section III STATUS CHANGE Name / Address Change Transfer from Division to COBRA Reinstatement of Subscriber Addition of Dependent Prior ID # I. SUBSCRIBER INFORMATION Subscriber Name (First, Last) Date of Birth (MM/DD/YYYY) Social Security / I.D. # Street Address / P.O. Box No. Apt. No. City State Zip Preferred Mobile Number Preferred Email III. DEPENDENT INFORMATION First Name Last Name (if different) Date of Birth (MM/DD/YYYY) Relationship Enroll In: Dental NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY POLICY Altus Dental does not discriminate on the basis of race, color, national origin, age, disability, or sex. Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-[PHONE REDACTED]. Português (Portuguese): ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para 1-[PHONE REDACTED]. Rev1123 MM/YY - QTY [BUG] I certify that all information is correct to the best of my knowledge. I understand that the effective date and termination date of my membership will be determined by my employer or plan sponsor in accordance with underwriting guidelines. If my employer requires employee contributions for this coverage, I authorize the deductions of these amounts from my wages periodically. Employee Signature Date Benefits Administrator Authorization Date