Add Employee and/or Dependents to a dental and/or vision plan  

          Dental Groups under 10 active members, Click here for a note about waiting periods for Dental Plans.

          DeltaCare Plan: Please Click here for important information on the DeltaCare enrollment process.

Who is submitting this form?
In case we have questions on this addition to the plan, please supply your information



Which Group is this employee to be added to?


Choose an action:

Employee Information


Choose Effective Date:    





Mail Issuing Materials to: 

Dependent Information
Please leave fields blank if you do not have dependents or children to enroll.                        
First Name     Last Name (if Different) Gender   Date of Birth

If your group has several plan options, please use the text box below to indicate which plans apply to this member. 
If you do not indicate which plan the member should be added to, we will add the member to the base plan for the group.
All Dependents will be added to the same plans as the employee unless noted.

Dental groups under 10 active members.  Submit proof of Prior Dental coverage to waive major waiting period.
Click here for a note about waiting periods for Dental Plans

Memo: Please give us any additional information that you feel is necessary to process this request.