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Information provided on the form will be forwarded to the dental insurance company providing coverage for the employee I understand that it is my responsibility to report any change in the eligibility of my dependents and that the benefits or services of the elected plan are coordinated with those provided by any other group dental, hospital or medical benefit or service plan. Copies of the dental plan enrollment authorization are maintained in confidential files of the state controller's office for five years.

All dependents listed will be considered enrolled I want to enroll myself and those dependents listed above in the plan elected ***addi tional documentation will be required for disabled and student st atus

‡maximum of three facilities per family.

Please attach a separate sheet for additional dependent information **additional documentation will be required for disabled and student status. Dental enrollment form for new enrollment, please complete all sections of this form For enrollment changes, please select the applicable “type of activity” in section a and provide the identification number and employee name in section c (also complete section d for dependent changes).

Dental and vision i authorize any payroll deduction that may be required towards the cost of this coverage I certify that the above information is true and correct to the best of my knowledge I understand that changes can only be made during the annual open enrollment period unless i experience a qualifying family status change, in which case the change must be consistent with that event, or. Other dental coverage information on the day this coverage begins, will you, your spouse (or domestic partner), or any of your dependents be covered under any other dental plan, policy or contract including another dental benefit providers of california, inc

Small business advantage enrollment/change form eligible employees electing coverage for themselves must enroll following completion of their eligibility period

Employees who do not enroll cannot enroll at a later time unless they show proof of loss of coverage under another dental program.

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