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Employee Enrollment Form

Dental Plan Policy GH-1112
Dental Plan Selection (pick one) Coverage: Date of Hire:
□ Standard □ Basic □ Deluxe □ Deluxe Plus □ Employee □Employee+Spouse
Orthodontia (pick one): □ Yes □No □Emp+Child(ren) □Emp+Family
Vision Plan Policy GHA-1157
Vision Plan Selection: Coverage: Group #

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□ Silver □ Gold □ Platinum

Employee Information

□New Hire □Open enrollment □ Change □ Termination □ COBRA □ Waive □ Other __________________

Employer: ____________________________________________________ Job Title: _____________________________________________

Employee: ____________________________________________________ Social Security #: _______________________________________

Address: ____________________________________________________ Date of Birth: _______________ Date of Hire: ________________

City, State, Zip: _______________________________________ Phone Number: _______________________________________

Gender: □ Male □ Female Marital Status: □ Single □ Married
Dependent Information
Dental Vision Relationship Name DOB SSN M F
☐ ☐ Spouse ☐ ☐
☐ ☐ Child ☐ ☐
☐ ☐ Child ☐ ☐
☐ ☐ Child ☐ ☐
☐ ☐ Child ☐ ☐
Other Insurance
If you or your dependents are currently covered under any other insurance, please list below. Attach an additional sheet of paper if necessary.
Name Carrier Group # ID # Phone #

Previous Insurance
If you or your dependents have been covered under any other group insurance in the last twelve (12) months, please list below (use back of page, if needed)
Name Carrier Group # Effective Date Termination Date

Group Dental Coverage is provided under the Group Dental Insurance Policy GH-1112 (and any state specifics) issued to the Group Policyholder
(policyholder may be a trustee group policyholder), and Group Vision Coverage under the Group Vision Policy GH-1157 (and any state specifics) issued to
the Group Policyholder (policyholder may be a trustee group policyholder in some states), all insured by Security Life Insurance Company of America,
Minnetonka, Minnesota.
By my signature below, I hereby apply for the coverage or coverage’s selected above. I represent/certify that I have read the applicable Fraud Notice
provided. I also hereby authorize payroll deductions from my earnings for any contributions required. This Authorization remains in effect until revoked by me
in writing.
California Law prohibits an HIV Test from being required or used by health insurance companies as a condition of obtaining health insurance coverage.
Important Fraud Notices
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
CA - For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Employee Signature: Date:
Printed Name:
Email to Eligibilty@Healthedgeinc.com or Fax 661.616.4889
Underwritten by: Security Life Insurance Company of America – Minnetonka, MN 55343
S11749