NORTH ROSE-WOLCOTT CENTRAL SCHOOL DISTRICT

Dental PlanEnro llment/Change Form

File Maintenance, Health Economics Group, Inc

Phone (585) 241-9500 Fax: (585) 24195- 18

enrollment@heginc.com

Date:

Subject:

Type of Coverage:

New Employee Dental Enrollment

Single

Employee Dental Change

Family

Cancel Dental Coverage

Name/Address Change

Name:

Gender:

Male

Female

Address:

SSN:

Birthdate:

Telephone: (

)

Dependents:

Name

*

Sex

Birthdate

Social Security No.

Spouse

Child

Child

Child

Child

*Indicate

F

if full-time student age 19 or over or indica

H

te if handicapped

Is spouse employed?

Yes

No

If yes, employer’s name:

Is anyone listed above covered by another dental plan? Yes

No

Policy Holder:

Persons Covered:

Plan:

ID Number:

Employee Signature:

Date:

Effective:

______/______/______

Facility:

Unit:

Employer Signature:

Date: