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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)*

MEMBER INFORMATION

Address*
MM slash DD slash YYYY
Would you like to add coverage for a Spouse?

SPOUSE INFORMATION

Spouse Name
MM slash DD slash YYYY
If spouse is 19 or older, is spouse a full-time student?

CHILDREN

Would you like to add coverage for a child?

Child 1

Child's Name
MM slash DD slash YYYY
If age is 19 or older, is child a full-time student?
Would you like to add coverage for a 2nd child?

Child 2

Child's Name
MM slash DD slash YYYY
If age is 19 or older, is child a full-time student?
Would you like to add coverage for a 3rd child?

Child 3

Child's Name
MM slash DD slash YYYY
If age is 19 or older, is child a full-time student?
Would you like to add coverage for a 4th child?

Child 4

Child's Name
MM slash DD slash YYYY
If age is 19 or older, is child a full-time student?
Would you like to add coverage for a 5th child?

Child 5

Child's Name
MM slash DD slash YYYY
If age is 19 or older, is child a full-time student?
Would you like to add coverage for a 6th child?

Child 6

Child's Name
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If age is 19 or older, is child a full-time student?

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:*

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