Dental Source of Missouri and Kansas, Inc
|Dental Source of Missouri and Kansas, Inc. |State Employee |
|Dental Health Care Plans |Enrollment Form |
|Toll Free: 1-800-369-3485 Local: 816-523-8900 |Plan E |
VENDOR# DS 1D
|Your Department AND Division Name: | |
PART 1 – MEMBERSHIP INFORMATION:
EFFECTIVE DATE:__________________
SOCIAL SECURITY NUMBER: ____ ____ ____ - ____ ____ - ____ ____ ____ ____ (required)
|LAST NAME |FIRST NAME MIDDLE |DATE OF BIRTH |
| |INITIAL | |
| | | |
|ADDRESS |CITY/STATE/ZIP | |
| | |WORK PHONE:___________________________________ |
| | | |
| | |HOME PHONE: |
PART 2 – DEPENDENT INFORMATION:
|Dependent Last Name |Dependent First Name |Date of Birth |Relation to Applicant |
| | | | |
| | | | |
| | | | |
| | | | |
DENTIST INFORMATION:(Select from listing attached)
|Dentist Name: |Office ID Number: |
| | |
COVERAGE TYPE (Check One)
|( SINGLE ($13.00 Per Month) | |* Please Fax or Mail a copy to Dental Source and your PAYROLL DEPARTMENT |
| | | |
| | |Authorized Payroll Deduction Amount: |
| | |$ |
| | | |
| | | |
| | |Semi-Monthly |
| | |Single: 6.50 – Couple $10.00 – Family $12.50 |
| | | |
|( MEMBER +1 ($20.00 Per Month) | | |
| | | |
|( FAMILY ($25.00 Per Month) | | |
| | | |
| | | |
PAYROLL DEDUCTION AUTHORIZATION:
I have read and understand the terms and conditions of the program and hereby request membership with Dental Source of Missouri and Kansas, Inc. I further authorize my employer to deduct from my salary the monthly membership fee listed above (Authorized Payroll Deduction Amount) for the Dental Source Coverage that I have selected.
X______________________________________________________________________________________
Applicant Signature Date Office Use Only
9/04
-----------------------
DS 1D
MEM/1
MEM+1
MEM/F
................
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