<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=828770110492813&ev=PageView&noscript=1" /> Individual Plan Application
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Individual Plan Application
Subscriber Information
First Name:*
Last Name:*
Mailing Address:*
City*
Zip Code:*
Social Security Number (Must include dashes)*
Date of Birth*
Phone Number*
Gender*

Email Address*
Please check the plan and type of coverage you are applying for *

Coverage*


Covered Dependents
List all covered dependents you are enrolling.
Spouse First Name
Spouse Last Name
Spouse Date of Birth
Spouse Gender

Dependent First Name
Dependent Last Name
Dependent Date of Birth
Dependent Gender

Dependent 2 First Name
Dependent 2 Last Name
Dependent 2 Date of Birth
Dependent 2 Gender

Dependent 3 First Name
Dependent 3 Last Name
Dependent 3 Date of Birth
Dependent 3 Gender

Dependent 4 First Name
Dependent 4 Last Name
Dependent 4 Date of Birth
Dependent 4 Gender

Dependent 5 First Name
Dependent 5 Last Name
Dependent 5 Date of Birth
Dependent 5 Gender

Additional Dependents - please include Name, DOB and Gender
Dependent children are covered through the end of the month in which they turn 26
Check here if you have been continuously covered under a dental plan for at least the last 3 months

If Yes, please tell us who was your dental benefits carrier (we may need proof prior coverage)
The effective date of your plan will be the first of the month following receipt of your completed enrollment form and payment or payment authorization. Enrollment forms must be received by the last working day of the month.
Choose Your Payment Method*
If paying an annual premium - please remit your check to Delta Dental of Wyoming, 6234 Yellowstone Rd, Cheyenne, WY 82009. Your check must be received as soon as possible after application submission or your policy will not become effective.
Please complete the following information for payment by Electronic Funds Transfer (Bank Draft)
Name of Financial Institution
Financial Institutions City, State, Zip
Type of Account (choose one)
Name on Account
Bank Routing Number
Bank Account Number
I authorize Delta Dental of Wyoming to inititate transactions from my above bank account for my pre-paid dental plan premiums.
Name/Signature: /s/
Date
Please carefully read the Agreement below. A signature is required
I certify the information contained in this application is true and complete to the best of my knowledge. I understand that misrepresentation of submitted data may cause this application and subsequent policy to be null and void. I further understand that covered services are eligible for payment only if my Agreement is in effect at the time the services are provided. I understand that notice of rate changes and/or plan modifications will be provided by Delta Dental of Wyoming at least 60 days before the effective date.
I authorize Delta Dental of Wyoming to conduct an electronic funds transfer (EFT) of my designated personal bank account until further notice for payment of my premiums. If I do not choose the EFT option, I will make an annual payment by personal check, in advance, for each annual coverage period. Regardless of the payment method, I understand that my enrollment is subject to Delta Dental approving my application and receiving my payment and if funds are not available or payment is not made on time, I (and my dependents) will no longer be eligible for coverage. I also understand that if I terminate or discontinue enrollment, I will not be able to re-enroll for a period of 36 months.
Enrollee Signature /s/*
Date Signed*
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Correspondence from Delta Dental of Wyoming
All correspondence regarding this plan will be conducted electronically unless you request to be contacted by mail. Correspondence will be sent to the email address listed on the front of this application. You must maintain a valid email address to ensure delivery and receipt of information regarding your plan. We will not send private health information in an email
Check here if you prefer to receive correspondence by mail
For Agent Use Only
Agent Name
Phone
Agent Date
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Agent Email Address