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