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Lineman Assurance Company TM 100 SW Market Street P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 DENTAL WAIVER FORM POLICYHOLDER INFORMATION Employer Name/Policyholder
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What is dental waiver form?
The dental waiver form is a document that allows an individual to waive their rights to dental coverage under a specific health insurance plan.
Who is required to file dental waiver form?
Individuals who already have dental coverage through another source, such as a spouse's employer, are required to file a dental waiver form.
How to fill out dental waiver form?
To fill out a dental waiver form, the individual must provide their personal information, details of their existing dental coverage, and sign the form to confirm their decision to waive dental benefits.
What is the purpose of dental waiver form?
The purpose of the dental waiver form is to inform the insurance provider that the individual does not require dental coverage through their plan due to having coverage elsewhere.
What information must be reported on dental waiver form?
The dental waiver form typically requires information such as the individual's name, contact details, existing dental insurance provider, policy number, and signature.
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