Get the free Dental Plan Enrollment Authorization PDF

Clear STATE OF CALIFORNIA Print DENTAL PLAN ENROLLMENT AUTHORIZATION STD. 692 (REV. 6-2000) PLEASE TYPE OR USE BALL POINT PEN, PRINT CLEARLY--SEND COMPLETED FORM TO PERSONNEL/PAYROLL OFFICE SECTION

How to fill out dental plan enrollment authorization

Who needs dental plan enrollment authorization?

1. Employees: All employees who wish to enroll in a dental plan offered by their employer need to fill out the dental plan enrollment authorization. This includes both new employees who are joining the company and existing employees who want to make changes to their dental coverage.
2. Dependents: In some cases, employees may also need to complete a dental plan enrollment authorization for their dependents, such as spouses or children, who will be covered under the dental plan.

How to fill out dental plan enrollment authorization:

1. Obtain the form: The dental plan enrollment authorization form can usually be obtained from the employer's human resources department or the dental insurance company. If it is not readily available, contact the relevant authority to request the form.
2. Personal Information: Fill out the required personal information, such as full name, address, date of birth, social security number, and contact information. Ensure that all information is accurate and up to date.
3. Employment Details: Provide details about your employment, including your job title, department, and any other relevant employment information as requested on the form.
4. Plan Selection: Indicate the dental plan you wish to enroll in by selecting the appropriate option provided on the form. If there are multiple plan options available, carefully review the details and choose the plan that best suits your needs.
5. Dependent Information: If you are enrolling dependents in the dental plan, provide their full names, dates of birth, and any additional requested details about them. Make sure to accurately provide all the necessary information for each dependent.
6. Signature: Read the authorization terms and conditions carefully and sign the form, indicating your agreement to the terms. This signature is vital as it signifies your consent and understanding of the dental plan enrollment process.
7. Submission: Once the form is correctly filled out and signed, submit it to the appropriate authority. Follow any additional instructions provided on the form regarding submission, such as submitting it to the human resources department or directly to the dental insurance company.

By following these steps, employees and their dependents can successfully fill out a dental plan enrollment authorization form, ensuring they have access to the dental coverage they desire.

For pdfFiller’s FAQs

What is dental plan enrollment authorization?

Dental plan enrollment authorization is a form or document that allows an individual to enroll in a dental plan.

Who is required to file dental plan enrollment authorization?

Any individual who wishes to enroll in a dental plan is required to file dental plan enrollment authorization.

How to fill out dental plan enrollment authorization?

To fill out dental plan enrollment authorization, one must provide personal information such as name, contact information, and any dependent information.

What is the purpose of dental plan enrollment authorization?

The purpose of dental plan enrollment authorization is to officially enroll an individual in a dental plan and provide access to dental benefits.

What information must be reported on dental plan enrollment authorization?

The information reported on dental plan enrollment authorization may include personal details, coverage options, and any dependents being enrolled.

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