Eight Digit Group Number

  Premier	________ - _______

  Advantage ________ - _______ Plus Premier

  Preferred	________ - 6______

  Advantage ________ - 8______

  DeltaCare	________ - 9______
	
	OPEN ENROLLMENT
			
Mail to:
P.O. Box 23700 Newark, NJ 07189-0001 (973) 285-4144

DENTAL ENROLLMENT FORM

Name of Employer
	
Effective Date of Coverage

GENERAL INFORMATION - THIS SECTION MUST BE COMPLETED - PLEASE PRINT CLEARLY

Name (Last)	(First)	(Middle)
	
Date of Birth

______ / ______ / ______
	
Social Security Number

___ ___ ___ - ___ ___ - ____ ___ ___ ____

Street Address
	
City, State, Zip
	
County

Date of Employment
	
Type of Coverage
	
Marital Status
	
Home Telephone

_____ / _____ / _____
	
  Single	  Parent/Child
  Husband/Wife	  Parent/Children
  Family
	
  Single
  Married
  Divorced/Separated

(	)

Enrollment
	
First Name - Last Name
	
Social Security Number
	
Date of Birth
	
Full-Time Student

Subscriber
		
________ - _______ - _______
	
/	/

Spouse*
		
________ - _______ - _______
	
/	/

Dependent
		
________ - _______ - _______
	
/	/
	
  Yes	  No

Dependent
		
________ - _______ - _______
	
/	/
	
  Yes	  No

Dependent
		
________ - _______ - _______
	
/	/
	
  Yes	  No

Dependent
		
________ - _______ - _______
	
/	/
	
  Yes	  No

* If spouse has other dental coverage, please list name and address of employer and other carrier:

				

I hereby represent that all information furnished is true and complete to the best of my knowledge and authorize my employer to make any required deduction from my wages.

______________________________________________	_______________________ Subscriber Signature	Date
	
Delta Use Only __________________ Entered __________________ Operator #