KPIC Group Dental Plan Enrollment

Applicant Information

SSN:

We will issue an alternative ID with the approval of coverage.  The SS# will not be shown on any correspondence.

Requested Effective Date:

The application and the premium must be received by Wolfpack Insurance Services, Inc by the 20th of the month prior to the request effective date.

Kaiser Medical Medical Record number:


Address:


City:                                                State:                Zip Code:
                    

Phone Number:


Email Address:


Email Invoice Option:
Yes, email me the invoice
No, please mail me the invoice


First Name:                                            Last Name:                                         Gender:                             Date of Birth:
                              

Dependent Information
  
  First Name Last Name (if different) Gender Date of Birth
Spouse
Child #1
Child #2
Child #3
Child #4
Child #5
 
Select your Payment Option

Automatic Draft or Monthly Invoice
Monthly automatic payment via automatic draft from your checking or savings account. (provide information below)
*If you choose Monthly automatic payment we will draft the initial payment from this account with the submittal of the application.

Monthly Invoicing to the member address listed above.
 
 
Monthly Automatic Payment form your bank account.
Monthly Drafts occur on the 15th of the month prior to the coverage month.

By selecting Monthly Automatic payment, I (we) hereby authorize Wolfpack Insurance Services Inc. to charge the applicable monthly dues for dental coverage to my account designated below.  I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction.  I understand eligibility begins the first of the month following my initial deduction.  

I (We) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law and the Rules of the National Automated Clearing House Association. I (We) further acknowledge that I (we) have retained a copy of this authorization when I (we) signed it.
 
You hereby authorize and request Wolfpack Insurance Services, Inc. to debit funds from your account at the financial institution indicated, and credit the funds according to the above instructions. Funds need to be on deposit at the designated financial institution on the evening prior to the effective date of the ACH debit. In the event of an error, you authorize  Wolfpack Insurance Servcies, Inc to take any and all action required to correct the error.
 
You must notify Wolfpack Insurance Services, Inc.  in writing if you would like to make any changes or to cancel the authorization.
You agree to indemnify and hold Wolfpack Insurance Servcies, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services action in refusing payment of the item, including claims of any joint account-holder, payee, or endorsee, or in failing to cancel or process an item as a result of incorrect information provided by you.   Upon cancellation Wolfpack Insurance Services will collect any outstanding premium due.
 
By clicking Submit Form below, you certify that the information you have given on this ACH Debit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.

 I also understand there cannot be any lapse of coverage in a 12-month period from the time of my enrollment.  I agree to comply with the terms outlined in the Combined Evidence of Coverage and Disclosure Form.  (My bank is authorized to make corrections if any should be necessary.)  
Automatic draft failures are subject to a $15.00 fee.

Bank Name:                                                       Type of Account:
          Checking  Savings

ABA Routing number (First nine digits number on left hand bottom of your check):


Account Number (Second series of number on the bottom of the check):


 
Credit Card Payment of initial premium and $2.00 convenience fee.
This is a two step process.  We will send you an email invoice through PayPal to make the credit card payment.  Please note
coverage will not be issued until you make this payment.

Email Address to send Credit Card Invoice to:
 
Terms and Conditions

Yes, I would like to enroll in the Kaiser Permanente Insurance Company (KPIC) Group Dental Plan for Federal Employees.  I understand that enrollment is voluntary.  By electing to enroll I agree to participate in the KPIC Trust (and/or any successor Trust), which holds the KPIC Group Dental Policy.  I understand that to be eligible for the Plan, I must be enrolled along with any of my dependents to be covered, in Kaiser Permanente's Traditional HMO Plan for Federal Enrollees.  I also understand that some covered dental services are subject to waiting periods.  I certify that to the best of my knowledge and belief, any information desclosed on this enrollment form, is accurate and that my answers are correct, true and complete.

Click here to acknowledge you have read the above statement:
I agree to the terms and conditions of the plan