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Company Name
Business Address 1
Business Address 2
City
State
ZipCode
Tax ID
SIC Code
Group Size
FTE Company Size
Business Structure
Effective Date
Probationary Period
Do you employ at least one individual that is not an owner and/or a spouse of an owner?
First Name
Last Name
Phone
Email
Mailing Address 1
Mailing Address 2
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ZipCode
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Waiving Health Insurance
First Name
Middle Initial
Last Name
DOB
Phone 1
Phone 2
Business Address 1
Business Address 2
City
State
ZipCode
Gender
Marital Status
SSN
PCP Name
PCP ID
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Current PCP?
Cobra?
Race/Ethnicity (select up to 5 options)
First Name
Middle Initial
Last Name
DOB
Business Address 1
Business Address 2
City
State
ZipCode
Gender
Marital Status
SSN
PCP Name
PCP ID
Current PCP?
Disabled?
Race/Ethnicity (select up to 5 options)
Plan Information
Benefits
Total
Monthly Costs
Premium
Individual -
Two Person -
Parent/Child(ren) -
Family -
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Terms and Conditions
Certification & Eligibility Guidelines 1. I hereby certify that my company is a Massachusetts based employer actively engaged in business and attest the information provided above is true and complete to the best of my knowledge and that I have the legal authority to execute this document on behalf of the company named above. I understand all dental coverage becomes effective upon the approval of the provider or carrier. 2. I further state that I am aware the dental plan retains the right to terminate coverage at any time if the statements made herein are not true and complete. 3 I appoint Small Business Insurance Agency, Inc. as the broker of record for the dental plan I have selected above and hereby authorize SBSB to notify the dental plan of this appointment. 4. I certify all current and future employees to be enrolled in the SBSB Group Dental Program actively work for financial compensation on a full-time basis of 20 hours per week. 5. I certify that my company contributes at least 50% towards the single and family premium rate. 6. New Hires: a new employee must become effective within 30 days from the first date of employment. Please Note: Delta Dental Plan requires 100% participation for groups of 2-9 lives; 90% participation for groups of 10-49. Proof of Business Documentation is required. (Example: Schedule C, WR1 SE) All groups subject to dental plan eligibility and underwriting requirements. All enrollment documents, including the employee’s application, must be completed, signed, dated, and submitted to SBSB five (5) business days prior to the desired effective date.
I agree to the terms and conditions.
E-signature
I am an authorized representative of this company and attest that all information is true and accurate
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Today's Date
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