Dental Source Dental Health Care Plans

Group Enrollment Form

Part 1	1. EMPLOYER NAME EFFECTIVE DATE
	^2. SOCIAL SECURITY NUMBER (required)		^3. NAME (LAST) (FIRST)
	^4. ADDRESS
	^(CITY) (STATE) (ZIP CODE)
	^5. WORK PHONE	^6 HOME PHONE		^7. DATE OF BIRTH^(month/day/year)	^8. SEX ^¡^Female^¡^Male

_{9. DEPENDANT INFORMATION - LIST ALL ELIGIBLE DEPENDANTS YOU WISH COVERED.}

Part 2	NAME LAST FIRST MI		^DATE OF BIRTH		^SEX				RELATION TO APPLICANT
Part 3	^Selected Dental Location Name							^Office Location #
Part 4	Select a plan and coverage type.			Membership Fee
	¡ Employee	¡		¡ $ 13.00
	¡ Employee + 1			¡ $ 20.00
	¡ Family			$ 29.00
Part 5	I have read and understand the terms and conditions of the program and hereby request membership with Dental Source of Missouri & Kansas, Inc. I further authorize my employer to deduct from my salary the $___________monthly membership fees for the Dental Source coverage that I have selected.
	^SIGNATURE					^DATE
Part 6	Waiver of Coverage: I have been offered the plan and elect not to participate at this time. I understand that I will not be eligible to enroll in this benefit until the company’s next open enrollment period or twelve months from this date.
	^SIGNATURE						^DATE

Date Received:		Date Approved		Approved By
Agent 20184	Broker Robyn Hamlin	SGA	Dist	Group