Fill and Sign the Claim Form Nj

DENTAL ENROLLMENT/CHANGE FORM The Prudential Insurance Company of America 2101 Welsh Road, Dresher PA 19025 Group.Insurance.Eligibility@Prudential.com Fax: 1-866-764-0547 A. EMPLOYEE INFORMATION Employee’s Last Name ______________________________________________________ First Name __________________________________________ Name of Employer _____________________________________________________________________________ MI ________ Group Contract No. ____________________________ Employee’s Address __________________________________________________________________________________________________________________________ Married Widowed Male – – / / / / Social Security No. ___________________________ Date of Birth __________________ Date Employed __________________ Single Divorced Female / / Effective Date of Coverage or Change __________________ Email Address______________________________________ – – Daytime Phone __________________________ Reason for Enrollment or Change Enroll: Annual Enrollment New Hire Terminate: Employee Coverage Qualifying Event Reason: _____________________________ Date / / Change: Name Dependent Coverage Termination Reason: _________________________ Address/Phone Number Other (Please Specify): _________________________ B. DENTAL COVERAGE ELECTION I ELECT THE FOLLOWING FOR ME AND MY DEPENDENT(S): Dental Plan Selection ___________________________________ Type of Coverage: Employee Employee/Spouse/Domestic Partner Employee/Child Employee/Children Employee/Spouse/Domestic Partner/Child(ren) C. DEPENDENTS TO BE COVERED OR DELETED Full Name (First, MI, Last) Relationship Sex Date of Birth Full-Time Student? When coverage begins, will family member have any other dental coverage? Enroll Delete M F / / Yes No Yes No Enroll Delete M F / / Yes No Yes No Enroll Delete M F / / Yes No Yes No Enroll Delete M F / / Yes No Yes No D. EMPLOYEE SIGNATURE Please review the following before completing this step. After review, indicate your acceptance or waiver of coverage below, sign and date this form, and return to your Benefits Administrator. You will receive complete plan information for the dental coverage you have elected. Acceptance or Waiver of Coverage Acceptance of Coverage. I am enrolling for coverage and I authorize my employer to deduct from my earnings (if employee contributions are required) until further notice my contributions for coverage under my employer’s dental plan. I understand that I cannot make an elective change in the coverage selected until the next annual enrollment period. Waiver of Coverage. I acknowledge that I have been given the opportunity by my employer to enroll in the employer’s dental plan and have elected not to enroll for that coverage at this time. I understand that if I decide to enroll in the dental coverage for me and/or any qualified dependent(s) at a later date, neither my qualified dependent(s) nor I will be eligible to enroll in the dental plan until (1) my employer’s next annual enrollment period, or (2) there is a qualifying life event as defined in the employer’s dental plan. I am waiving coverage for: Myself Spouse/Domestic Partner Qualified Dependent(s) Please review and sign the reverse side. GL.2010.057-NY GL0932401 G L 0 9 3 2 4 0 1 Ed. 04/2014 IMPORTANT NOTICE: For residents of all states except Alabama, the District of Columbia, Florida, Maryland, Kentucky, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Utah, Vermont, Virginia and Washington; WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS —Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS —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. KENTUCKY RESIDENTS —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. MARYLAND RESIDENTS—Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS —Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. PENNSYLVANIA and UTAH RESIDENTS —Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. PUERTO RICO RESIDENTS —Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. VERMONT RESIDENTS —Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS —Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. WASHINGTON RESIDENTS —Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. FLORIDA RESIDENTS —Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YORK RESIDENTS —Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. GL.2010.057-NY GL0932402 G L 0 9 3 2 4 0 2 Ed. 04/2014 Ohio Disclosure — WARNING: IF YOU AND YOUR FAMILY MEMBERS ARE COVERED BY MORE THAN ONE HEALTH CARE PLAN, YOU MAY NOT BE ABLE TO COLLECT BENEFITS FROM BOTH PLANS. EACH PLAN MAY REQUIRE YOU TO FOLLOW ITS RULES OR USE SPECIFIC DOCTORS AND HOSPITALS, AND IT MAY BE IMPOSSIBLE TO COMPLY WITH BOTH PLANS AT THE SAME TIME. BEFORE YOU ENROLL IN THIS PLAN, READ ALL OF THE RULES VERY CAREFULLY AND COMPARE THEM WITH THE RULES OF ANY OTHER PLAN THAT COVERS YOU OR YOUR FAMILY. I represent that all information supplied above is true and correct. I have thoroughly reviewed understand and accurately responded to all questions and information on this form. Employee Signature _____________________________________________________ Date (Month/Day/Year) _____ / _____ / _____ © 2014 Prudential Financial Inc. and its related entities. Prudential, the Prudential logo and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. Dental Insurance coverage is issued by The Prudential Insurance Company of America, Newark NJ. Dental Support: 877-471-3368. Please refer to the Booklet-Certificate for all plan details, including any exclusions, limitations and restrictions which may apply. Contract provisions may vary by state. California COA #1179, NAIC #68241. Contract Series: 83500. GL.2010.057-NY GL0932403 G L 0 9 3 2 4 0 3 32505 Ed. 04/2014