IndividualPlanApplication
Subscriber Information
Name: Phone: Address: SSN: City: State: ZIP: Birthdate:
Benefit Summary for Both Plans
DeltaDentalPPO / Out-of-network / WaitingPeriodsDiagnosticandPreventive / 100%* / 80%* / None
Sealants / 80% / 60% / None
Basic Services / 80% / 60% / None
Fillings / 80% / 60% / 6 months
Endodontics / 50% / 40% / 6 months
Periodontics / 50% / 40% / 6 months
OralSurgery / 50% / 40% / 6 months
MajorRestorations / 50% / 40% / 12 months
Prosthodontics / 50% / 40% / 12 months
Implants / 50% / 40% / 12 months
ContractYearMaximum / $1,000permember
IndividualDeductible / $50percontractyear
FamilyDeductible / $150percontractyear
Deductibledoesnot applytoin-networkdiagnosticpreventiveservices.*Co-payoptionrequires$20officevisitco-payfor
diagnosticpreventiveservices.
Premium-Options
Standard PlanCo-Pay Plan
MonthlyAnnualmonthlyAnnual
Individual$32.78$393.36$29.99$359.88
Ind.+1dependent$62.44$749.28$56.99$683.88
Ind.+2ormoredependents$110.11$1,321.32$99.99$1,199.88
Note:Formonthlybillingoption,add$1.50monthlybillingfeetopremium. Avoidthisfee bypayingannually.
Select plan and payment method
Selectaplan(chooseone):oStandardoCo-pay
Selectmethodofpayment(chooseonlyone):
oCheck(annualonly)MakecheckpayabletoDeltaDentalofTennessee
oMonthlycreditcard / Visa/MasterCard / AccountnumberExp.date(MMYY)oAnnualcreditcard / (pleasecircleone)
oMonthlybankdraft / Bankname:
oAnnualbankdraft / Account#:
Routing#:
Dependents to be covered (if any)
NameBirthdateSSNRelation(spouseorchild)
Certification and Signatures
Thisistocertify thattheinformationcontainedinthisapplicationistrue,completeandaccurate.Itisunderstoodthattherates,terms,andconditions ofanyrelatedcontractissuedbyDeltaDentalof Tennessee (DDTN)shallbebasedupontherepresentationsinthisapplicationandotherinformation previouslyprovidedtoDDTN.Itisfurtherunderstoodthatifanyinformationorrepresentationisnot true,completeoraccurate,thatDDTNmayadjusttherates,termsorconditions and/or cancelany contract.Furthermore,youcertify thatyouareapplyingforthispolicyintheStateofTennessee. This applicationshallbecomeapartofthecontractissuedbyDDTN.Itisacrimetoknowinglyprovide false,incompleteormisleadinginformationtoaninsurancecompanyforthepurposesofdefrauding thecompany.Penaltiesincludeimprisonment,fines,anddenialofcoverage.
IndividualherebyagreesthatifDDTNacceptsthisapplicationandissuesasignedcontract,the Individualshallbeboundbythetermsandconditions ofsaidcontract.Individualfurtheragreesto paythepremiumsdefinedinsaidcontractinaccordancewiththetermsofsaidcontract.Individual alsorecognizesthatthiscontractmayonlybemodifiedbywrittendocumentissuedbyDDTNas definedinthecontract.
Iherebyauthorize DDTN,itssubsidiaries andaffiliatestochargemycreditcardortoinitiateautomatic withdrawals(ACH) frommyaccount,asindicatedonthisapplication,forpremiumsdue.This authorizationwillremainineffect untilDDTNhasreceivedwrittennoticefrommeofitstermination and/or mypaymentobligationhasbeensatisfied.Ifthebillingamount changes,DDTNwillprovidea minimumof10 days’ noticetothecardholder,ifapplicable.IunderstandthatIamresponsible forany feesincurred duetomypaymentbeingrejectedforprocessingbymybank,ifapplicable.
Signature Date Printedname
Howdidyouhearaboutthisplan? Brokername(if any) David Moore – Benefit Brokers, LLC
Brokerconfirmationemailaddress
Mailcompletedapplicationto:DeltaDentalofTennessee
6607 CollectionCenterDrive
Chicago,IL60693
176 v3
cc11/12