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OOIDA Headquarters: 1 NW OOIDA Dr., Grain Valley, MO 64029
(816) 229-5791
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Group Dental Enrollment
Group Dental Benefit Plan Enrollment
"
*
" indicates required fields
DENTAL BENEFITS PLAN
I wish to apply for: (Plan Sponsor: OOIDA, Group Policy Number: 376839)
*
The Value Plan
The Premier Plan
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SPOUSE INFORMATION
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*
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If spouse is 19 or older, is spouse a full-time student?
Yes
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CHILDREN
Would you like to add coverage for a child?
Yes
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Child 1
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Last
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MM slash DD slash YYYY
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If age is 19 or older, is child a full-time student?
Yes
No
Would you like to add coverage for a 2nd child?
Yes
No
Child 2
Child's Name
First
Last
Gender
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security Number
If age is 19 or older, is child a full-time student?
Yes
No
Would you like to add coverage for a 3rd child?
Yes
No
Child 3
Child's Name
First
Last
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Male
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Date of Birth
MM slash DD slash YYYY
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If age is 19 or older, is child a full-time student?
Yes
No
Would you like to add coverage for a 4th child?
Yes
No
Child 4
Child's Name
First
Last
Gender
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security Number
If age is 19 or older, is child a full-time student?
Yes
No
Would you like to add coverage for a 5th child?
Yes
No
Child 5
Child's Name
First
Last
Gender
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security Number
If age is 19 or older, is child a full-time student?
Yes
No
Would you like to add coverage for a 6th child?
Yes
No
Child 6
Child's Name
First
Last
Gender
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security Number
If age is 19 or older, is child a full-time student?
Yes
No
Verify
I hereby request coverage under the Dental Plan issued by Ameritas Life Insurance through the Owner-Operator Independent Drivers Association. Falsifying information can result in the termination of coverage for you and your dependents.
YOU MUST SELECT THE CHECK THE FOLLOWING BOXES AND SIGN THE FORM:
*
I UNDERSTAND AND AGREE
Δ
Go to
Form 2290
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