Ohio DentaTrust
Application and Change Form for
Individual Dental Insurance
c/o Dental Care Plus, Inc.
100 Crowne Point Place
Cincinnati, OH 45241
www.dentalcareplus.com
Customer Service: [(800)-367-9466]
Required fields (front and back) are marked with an asterisk (*) and must be completed to ensure enrollment.
1. * LAST NAME (Subscriber)
2. * FIRST NAME:
3. * SOCIAL SECURITY NO.:
4. * DOB:
5. GENDER
F / M
6. * HOME ADDRESS:
7. * CITY
10. * COUNTY
8. * STATE:
11. * PHONE NUMBER:
9. * ZIP:
12. E-MAIL:
ELIGIBLE DEPENDENT(S) TO BE COVERED UNDER THIS POLICY
13. FIRST NAME
14. LAST NAME
(IF DIFFERENT FROM SUBSCRIBER)
TOTAL CHILD COUNT:
15. DATE OF BIRTH
16. CHECK IF DEPENDENT IS
19-26
TOTAL ADULT COUNT:
PLAN SELECTION
17. PLAN: Select plan you are enrolling in:
Pediatric High
Pediatric Low
Family High
Family Low
For court ordered dependent and/or domestic partner, legal documentation/affidavit must be attached. Contact Dental Care Plus to request
domestic partnership form, if needed. If dependent does not reside with eligible member, please provide address on separate sheet.
18.
REASON FOR SUBMISSION
CHECK ONE:
 New Application  Reinstatement  Termination  Status change
to
IF TERMINATION OR CHANGE, PLEASE COMPLETE BELOW (CHECK ALL THAT APPLY):
 Name:
From
To
 Address:
From
To
 Add dependent
Name
 Remove dependent
Name
 If changing rates, indicate the new selection:  Child (0-19)  Individual (19+)  2 Individuals  Individual + Child  Individual + Children  Family
 Payment method (You must complete back)
Termination (Reason):
 Relocated out of Ohio
 Have other Dental Plan
 Other
 Non-payment
 Deceased
COVERAGE PERIOD
The initial term of your policy will be one year from the Effective Date. After the initial term, this policy will automatically renew year to
year establishing a new Effective Date each year until a Change Form is submitted or until this Agreement is terminated as provided
herein. This policy may be terminated upon thirty (30) days written notice to Dental Care Plus. You must wait at least one year after your
cancellation before you can enroll again as a subscriber. Applications postmarked by the 20th of the month will become effective the 1st
of the following month. Example - an Application postmarked June 20 will have an Effective Date of July 1. An Application postmarked
June 21 will have an Effective Date of August 1.
To complete this application, you must select one payment option and sign section 19 on back.
Benefits provided by Dental Care Plus, Inc.
DQ OH 100 – HIX – INDIVIDUAL
REV 7/2013
*PAYMENT INSTRUCTIONS
19.
*SELECT ONLY ONE PAYMENT METHOD AND FOLLOW INSTRUCTIONS:
Rates vary according to region. Please see enclosed rates or call [Dental Care Plus] for your region rates.
Premiums are due by the 20th of each month, prior to the month of coverage.
PAYMENT METHOD 1
AUTOMATIC MONTHLY WITHDRAWAL
FROM BANK ACCOUNT (AUTOMATED CLEARING HOUSE (ACH) PAYMENTS)
ACH payments occur on the 20th of the month (or next business day) prior to coverage.
Please make your initial payment by check payable to Dental Care Plus with this
Application and postmarked by the 20th of month for coverage effective the first day of
following month. You must sign the Authorization Agreement and attach a voided check
to this Application for all future premiums to be deducted from the bank account
indicated below by [Crosby Benefit Systems, Inc.]
AUTHORIZATION AGREEMENT FOR ACH Payments
Please select coverage:
 One Child (0-19)
 Two+ Children (0-19)
 Subscriber Only
 Subscriber + Spouse
 Subscriber + Children
 Family
$
$
$
$
$
$
+ Annual One-time Enrollment Fee $
+ Monthly Handling Fee
$
(applies to direct debits
Total Due
$
25.00
1.00
I do hereby authorize [Crosby Benefit Systems, Inc.], agent for Dental Care Plus,
hereinafter named the COMPANY, to initiate recurring (debit or credit) entries to my
(Checking Account / Savings Account) as indicated and named below as the
depository financial
institution, hereafter named FINANCIAL INSTITUTION. I acknowledge that the origination of ACH transactions to my account must comply with the
provisions of U.S. law. Furthermore, if any such debit(s) should be returned Non-Sufficient Funds, I authorize the COMPANY to collect such debit(s)
by electronic debit and subsequently collect a returned debit Non-Sufficient Funds fee of $25.00 per item by electronic debit from my account
identified below. I am a duly authorized check signer on the financial institution account identified below, and authorize all of the above as evidenced
by my signature below.
Financial Institution:
State: _______
Branch: _______ City: _______________
Zip: ________
Routing Number:
Acct. Number:
This authorization is to remain in full force and effect until the COMPANY has received written notification from me of its termination with
30 days notice.
Name
Signature
PAYMENT METHOD 2
Please select coverage:
ANNUAL PREMIUM PAYABLE BY CHECK
Make check payable to DentaQuest with this Application postmarked by the 20th of month
for coverage effective the first day of the following month. In the event there are not
sufficient funds to cover my check, I agree to pay a $25 Non-Sufficient Funds fee.
Name
Date
Signature
Date
 One Child (0-19)
 Two+ Children (0-19)
 Subscriber Only
 Subscriber + Spouse
 Subscriber + Children
 Family
$
$
$
$
$
$
+ Annual One-time Enrollment Fee $
Total Due
$
25.00
TERMS: I agree to enroll in this Dental Care Plus dental plan. I authorize my dentist who has rendered services to me or my covered dependents to
make available to Dental Care Plus, dental records or information regarding said services as permitted by law.
I understand that I am covered on the first of the month following receipt of my check in the correct amount and Application postmarked by the 20th of the
prior month, provided I meet eligibility requirements in accordance with the underwriting guidelines of Dental Care Plus. Additionally, I understand this is a one
year automatically renewing policy.
I understand that there is a six month waiting period on basic restorative services and a twelve month waiting period on major restorative services for adults
(20+). I understand there is a 24 month waiting period on orthodontic services for children (0-19).
I certify that all information is true and correct to the best of my knowledge. Also, I have completed all asterisked (*) fields, selected only one payment method
and enclosed a check payable to Dental Care Plus for the correct amount.
NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer by filing a statement of claim or an application containing any
false, incomplete or missing information is guilty of a felony of the third degree.
19. *Subscriber Signature
20.
Date
BROKER INFORMATION
If Broker is included please enter information below:
Broker / Firm Name
Broker License Number
Tax ID Number
General Agent / Firm Name
General Agent License Number
Tax ID Number