DENTAL SERVICE CENTER Dental and Vision Care Plans Offered by Northrop Grumman Federal Credit Union Post Office Box 3907 • Gardena, CA 90247-7599 Phone: 888·293·4903 • Fax: 310·323·7881 Welcome to the 2018-2019 Dental and Vision Care plan Enrollment Season! Did you know you can get quality, affordable dental and vision coverage for yourself and your family, and children can now be on your plan until age 26 with no student verification. Just enroll in any of the options below during this annual, limited open enrollment period. When we receive your enrollment no later than June 04, 2018, your coverage will take effect on July 1, 2018. If you have questions, call us toll- free 1-888-293-4903 option 1. Choose a dental care plan from CIGNA and VISION care coverage through VSP! Maximize savings with the CIGNA Dental Care ® (DHMO) plan. Why pay more than you have to for dental care? The CIGNA DHMO plan has comprehensive coverage, including orthodontic coverage for both children and adults. With the DHMO plan, you choose a primary dentist from the network at enrollment. Specialty care is available with a referral approved for payment. No deductibles, no claim forms, no annual maximums! Keep in mind, there is no out-of- network coverage with a DHMO plan. Finding a DHMO network dentist is easy! Search online at www.cigna.com or call for live customer service - 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using our plan ID 3214092. Balance freedom and savings with the CIGNA Dental PPO (DPPO)! As a DPPO customer, you may visit any licensed dentist, with no referrals required for specialty care. Choosing a CIGNA Advantage Network dentist (or specialist) will save you money on your dental bills because CIGNA Advantage Network dentists agree to offer discounts to CIGNA customers. In addition, they cannot charge you more than their contracted rates for covered services. Finding an Advantage Network dentist is easy! Search online at www.cigna.com or call for live customer service - 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using our plan ID 3214092. Vision Service Plan (VSP) Choice Plan: VSP is the largest vision care provider in the United States, with over 71,000 access points. Visit www.vsp.com or call 1-800-877-7195 to locate a provider. Inside this kit, you will find plan details, rates, payment options and enrollment forms for the Dental and Vision Care Plan options. Be sure to read the enclosed plan materials carefully before making a decision. When you’re ready to enroll, complete the enrollment form(s) for the coverage you want to have and use the enclosed envelope to return your form(s) to us. You must complete separate enrollment forms to enroll for both dental and vision coverage. You must also include separate checks for payment: each made payable to “Dental Service Center”. You can send your first quarterly payment, or your entire annual premium amount. We must receive your enrollment form(s) and check(s) no later than June 04, 2018 for coverage to begin on July 1, 2018. . Please Note: If you cancel during the 1 st year of enrollment there is NO opportunity for reinstatement. If you cancel after the 1 st year, there is a 2-year wait for reinstatement. If you are requesting this kit after our initial open enrollment deadline, there are pro-rated rates and enrollment deadlines for the time you are requesting. NO enrollment during the last quarter. Please see the rate sheet for details. Questions? Just call us toll-free at 1-888-293-4903, option 1. To your good health, DENTAL SERVICE CENTER
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DENTAL SERVICE CENTER Dental and Vision Care Plans Offered by Northrop Grumman Federal Credit Union
Post Office Box 3907 • Gardena, CA 90247-7599
Phone: 888·293·4903 • Fax: 310·323·7881
Welcome to the 2018-2019 Dental and Vision Care plan Enrollment Season!
Did you know you can get quality, affordable dental and vision coverage for yourself and your family, and
children can now be on your plan until age 26 with no student verification. Just enroll in any of the
options below during this annual, limited open enrollment period. When we receive your enrollment no
later than June 04, 2018, your coverage will take effect on July 1, 2018. If you have questions, call us toll-
free 1-888-293-4903 option 1.
Choose a dental care plan from CIGNA and VISION care coverage through VSP!
Maximize savings with the CIGNA Dental Care® (DHMO) plan.
Why pay more than you have to for dental care? The CIGNA DHMO plan has comprehensive coverage,
including orthodontic coverage for both children and adults. With the DHMO plan, you choose a
primary dentist from the network at enrollment. Specialty care is available with a referral approved for
payment. No deductibles, no claim forms, no annual maximums! Keep in mind, there is no out-of-
network coverage with a DHMO plan. Finding a DHMO network dentist is easy! Search online at
www.cigna.com or call for live customer service - 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using
our plan ID 3214092.
Balance freedom and savings with the CIGNA Dental PPO (DPPO)!
As a DPPO customer, you may visit any licensed dentist, with no referrals required for specialty care.
Choosing a CIGNA Advantage Network dentist (or specialist) will save you money on your dental
bills because CIGNA Advantage Network dentists agree to offer discounts to CIGNA customers. In
addition, they cannot charge you more than their contracted rates for covered services. Finding an
Advantage Network dentist is easy! Search online at www.cigna.com or call for live customer service
- 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using our plan ID 3214092.
Vision Service Plan (VSP) Choice Plan:
VSP is the largest vision care provider in the United States, with over 71,000 access points. Visit
www.vsp.com or call 1-800-877-7195 to locate a provider.
Inside this kit, you will find plan details, rates, payment options and enrollment forms for the Dental and
Vision Care Plan options. Be sure to read the enclosed plan materials carefully before making a decision.
When you’re ready to enroll, complete the enrollment form(s) for the coverage you want to have and use the
enclosed envelope to return your form(s) to us. You must complete separate enrollment forms to enroll for
both dental and vision coverage. You must also include separate checks for payment: each made payable to
“Dental Service Center”. You can send your first quarterly payment, or your entire annual premium
amount. We must receive your enrollment form(s) and check(s) no later than June 04, 2018 for
coverage to begin on July 1, 2018. . Please Note: If you cancel during the 1st year of enrollment there is
NO opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year wait for reinstatement.
If you are requesting this kit after our initial open enrollment deadline, there are pro-rated rates and
enrollment deadlines for the time you are requesting.NO enrollment during the last quarter. Please see the
rate sheet for details.
Questions? Just call us toll-free at 1-888-293-4903, option 1.
To your good health,
DENTAL SERVICE CENTER
CIGNA Dental Care (HMO) CIGNA Dental PPO
Member Only 25.06 46.28
Member + One 49.17 77.31
Member + Family 68.56 114.94
Important Information about Selecting a CIGNA Dental Plan
D2750 Crown – Porcelain Fused to High Noble Metal $185 $1575
D6750 Crown – Porcelain Fused to High Noble Metal $185 $1500
D6240 Pontic – Porcelain Fused to High Noble Metal $185 $1500
D6010 Surgical placement of implant; Endosteal implant (Limit 1 implant per calendar year) $1025 $3054
D6060 Implant crown-Porcelain fused to Metal $530 $1950
D9220 General Anesthesia – First 30 minutes $160 $505 *Estimated cost without dental coverage are based on Connecticut General Life Insurance Company analysis on average charge for each dental procedure based on geographic
distribution of CIGNA Dental Care membership and national claims analysis, prepared in 2014. Actual charges without dental coverage may differ from your area charges or
local dentist’s fees.
Cigna Dental Benefit Summary
Dental Service Ctr/Flight Plan Financial Plan Renewal Date:7/1/2018
Insured by: Cigna Health and Life Insurance Company
This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents
to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.
Cigna Dental PPO
Network Options In-Network:
Cigna DPPO Advantage Network
Out-of-Network:
Non-Network
Reimbursement Levels Based on Contracted Fees Maximum Allowable Charge
Policy Year Benefits Maximum Applies to: Class I, II, III and IX expenses
$2,000
$1,500
Annual Deductible Individual
Family
$50
$150
$50
$150
Benefit Highlights Plan Pays You Pay Plan Pays You Pay
Class I: Diagnostic & Preventive Oral Exams
Cleanings: prophylaxis
X-rays: bitewing
Fluoride Application
Sealants: per tooth
Space Maintainers: non-orthodontic
100%
No Deductible
No Charge
80%
No Deductible
20%
No Deductible
Class II: Basic Restorative X-rays: full mouth
X-rays: panoramic
X-rays: periapical
Emergency Care to Relieve Pain
Restoration: fillings
Oral Surgery: simple extractions
Cleanings: periodontal maintenance
Periodontics: osseous surgery
Periodontics: periodontal scaling & root planing
Endodontics: root canal therapy
80%
After Annual
Deductible
20%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Class III: Major Restorative Anesthesia: general and IV sedation
Oral Surgery: oral surgical procedures
Oral Surgery: extractions of impacted teeth
Repairs: Bridges, Crowns and Inlays
Repairs: Dentures
Denture Relines, Rebases and Adjustments
Inlays and Onlays
Stainless Steel and Resin Crowns
Crowns, Bridges and Dentures
Prosthesis Over Implant
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Class IX: Implants
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Benefit Plan Provisions:
In-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the
dentist according to a Fee Schedule or Discount Schedule.
Non-Network Reimbursement For services provided by non-network dentist, Cigna Dental will reimburse according to the
Maximum Allowable Charge. The dentist may balance bill up to their usual fees.
Cross Accumulation All deductibles, plan maximums, and service specific maximums cross accumulate between in and
out of network. Benefit frequency limitations are based on the date of service and cross accumulate
between in and out of network.
Policy Year Benefits Maximum The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.
Benefit-specific Maximums may also apply.
Annual Deductible This is the amount you must pay before the plan begins to pay for covered charges, when applicable.
Benefit-specific deductibles may also apply.
Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $500 is
proposed.
Alternate Benefit Provision When more than one covered Dental Service could provide suitable treatment based on common
dental standards, Cigna HealthCare will determine the covered Dental Service on which payment
will be based and the expenses that will be included as Covered Expenses.
Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with
the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer
radiation, organ transplants and chronic kidney disease. There’s no additional charge for the
program, those who qualify get reimbursed 100% of coinsurance for certain related dental
procedures. Eligible customers can also receive guidance on behavioral issues related to oral health
and discounts on prescription and non-prescription dental products. Reimbursements under this
program are not subject to the plan deductible, but will be applied to and are subject to the plan
annual maximum. Discounts on certain prescription and non-prescription dental products are
available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire
discounted charge. For more information including how to enroll in this program and a complete
list of program terms and eligible medical conditions, go to www.mycigna.com or call customer
service 24/7 at 1.800.CIGNA24. Benefit Limitations:
Missing Tooth Limitation Provision For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise
payable until covered for 24 months; thereafter, considered a Class III expense.
Oral Exams 1 per 6 consecutive months
X-rays: bitewing 1 set per 12 consecutive months, limited to 4 films per set
X-rays: full mouth or panoramic 1 per 60 consecutive months
X-rays: periapical 4 per 12 consecutive months if not in conjunction with an operative procedure
X-rays: Intraoral occlusal 2 per 12 consecutive months
Cleaning: routine 1 prophylaxis (Class I) or periodontal maintenance (Class III) per 6 consecutive months
Fluoride Application 1 per 12 consecutive months for children under age 14
Sealants: per tooth 1 treatment per lifetime for children under age 14; payable on unrestored permanent bicuspid or
molar teeth only
Space Maintainers Limited to non-orthodontic treatment for children under age 14
Restoration: fillings 1 per 12 consecutive months; applies to replacement of identical surface fillings only, no
composite, white/tooth colored fillings on bicuspid or molar teeth
Inlays and Crowns
Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for
non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.
Replacement must be indicated by major decay. For people under age 16, benefits for crowns and
inlays are limited to resin or stainless steel.
Stainless Steel and Resin Crowns 1 per 36 consecutive months for children under age 16
Endodontic Treatment Root canal retreatment 1 per 24 consecutive months, based on necessity
Periodontal Scaling and Root Planning 1 per quadrant per 36 consecutive months
Dentures and Partials Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired
Denture Adjustments Covered if more than 12 consecutive months after installation; 1 per 12 consecutive months
Denture Repairs Covered if more than 12 consecutive months after installation
Denture Rebases and Relines Covered if more than 12 consecutive months after installation; 1 per 36 consecutive months
Prosthesis Over Implant
1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the
amount payable for non-precious metals. No porcelain or white/tooth colored material on molar
crowns or bridges
Bridges
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.
Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth
colored material on molar crowns or bridges
Model Payable only in conjunction with orthodontic workup
Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following:
Procedures and services not listed under Benefit Highlights;
Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet;
Restorative: core buildup; labial veneers; precious or semi-precious metals for crowns, bridges, pontics and abutments; restoration of teeth which have
been damaged by erosion, attrition or abrasion;
Periodontics: bite registrations; splinting; Prosthodontics: overdentures; precision or semi-precision attachments;
Get the best in eye care and eyewearwith NGC Retirees and VSP® VisionCare.Why enroll in VSP? We invest in the things you value most—the best care at the lowest out-of-pocket costs. Because we’rethe only national not-for-profit vision care company, you cantrust that we’ll always put your wellness first.
You’ll like what you see with VSP.Value and Savings. You’ll enjoy more value and the lowest out-of-pocketcosts.
High Quality Vision Care. You’ll get the best care from a VSP provider,including a WellVision Exam®—the most comprehensive exam designedto detect eye and health conditions.
Choice of Providers. The decision is yours to make—choose a VSP doctor,a participating retail chain, or any out-of-network provider.
Great Eyewear. It’s easy to find the perfect frame at a price that fits yourbudget.
Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective, review yourbenefit information.
Find an eye care provider who’s right for you. To find a VSP provider,visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID cardnecessary. If you’d like a card as a reference, you can print one onvsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete whenyou see a VSP provider.
Choice in EyewearFrom classic styles to the latest designer frames, you’ll find hundreds ofoptions. Choose from featured frame brands like bebe®, Calvin Klein,Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more1. Visit vsp.com tofind a Premier Program location that carries these brands. Prefer to shoponline? Check out all of the brands at Eyeconic.com, VSP's online eyewearstore.
Enroll in VSP today.You'll be glad you did.Contact us. 800.877.7195vsp.com
Every 12 months$20WellVision Exam Focuses on your eyes and overall wellness
See frame and lenses$25Prescription Glasses
Every 24 monthsIncluded inPrescription
GlassesFrame
$150 allowance for a wide selection of frames$170 allowance for featured frame brands20% savings on the amount over your allowance$80 Costco® frame allowance
Every 12 monthsIncluded inPrescription
GlassesLenses Single vision, lined bifocal, and lined trifocal lenses
Average savings of 20-25% on other lens enhancements
Every 12 monthsUp to $60Contacts (instead ofglasses)
$150 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)
As needed$20Diabetic Eyecare PlusProgram
Services related to diabetic eye disease, glaucoma and age-relatedmacular degeneration (AMD). Retinal screening for eligible memberswith diabetes. Limitations and coordination with medical coveragemay apply. Ask your VSP doctor for details.
Glasses and Sunglasses
Extra Savings
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12months of your last WellVision Exam.
Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam .............................................................................. up to $45Frame ............................................................................ up to $70Single Vision Lenses ........................................... up to $30
Lined Bifocal Lenses ........................................... up to $50Lined Trifocal Lenses ......................................... up to $65
Progressive Lenses ............................................. up to $50Contacts .................................................................... up to $105
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between thisinformation and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.
Contact us. 800.877.7195 | vsp.com1Brands/Promotion subject to change.
Child must be under the age of 26 and student verification is no longer required.
Rates are payable annually by full payment or quarterly by automatic checking or savings
account deductions (ACH). Any returned Check or ACH is subject to a $20.00 fee (See
agreement below).
When quarterly automatic deductions are elected, the first quarterly payment for each
coverage plan selected must be made with a separate check (payable to the Dental Service
Center) submitted with each signed enrollment form.
To cancel coverage, written notice must be received by the Dental Service Center
no later than the 5th of the month prior to the month the coverage will terminate.
Please Note: If you cancel during the 1st year of enrollment there is NO
opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year
wait for reinstatement.
CIGNA
Dental
HMO
P5I0X
No dental offices in the following states: AK, DE, HI, ID ,ME, MT, ND,
NH, NM, PR, RI, SD, VT, WV, WY
Payment Options: Quarterly Annual
Member Only $75.18 $300.72
Member + One $147.51 $590.04
Member + Family $205.68 $822.72
CIGNA
Dental
Preferred
Provider
Organization
(PPO)
Advantage Network
Available in all states. NOTE: The $50 deductible and $2,000 in-Advantage
Network or $1,500 out-of-network maximum is based on the plan year.
Payment Options: Quarterly Annual
Member Only $138.84 $555.36
Member + One $231.92 $927.72
Member + Family $344.82 $1379.28
VSP Vision
Care Plan
Choice Plan
Available in all states.
Payment Options: Quarterly Annual
Member Only $35.91 $143.64
Member + One $55.59 $222.36
Member + Family $80.07 $320.28
Authorization Agreement for Quarterly Automatic Checking or savings Account Deductions – By enrolling in any of the
dental or vision care plans above, I indicate the following:
I have a checking account at the financial institution named on the enclosed check and, for all debit entries, shall have
funds sufficient to pay such entries. Electronic debit entries shall be initiated by Dental Service Center to pay dental
and/or vision plan costs and other charges for the coverage plans selected and the entries shall constitute my receipt for
the transaction (s).
No payment to Dental Service Center shall be deemed to have been made unless and until Dental Service Center received
actual credit. I also understand that if corrections of the entry are necessary, it may involve an adjustment to my account.
I understand my direct electronic payment of the premium due will be debited on or about the 5th day of each
month prior to the following calendar quarter for which premium is due. (For example, the April-May-June
quarterly premium will be deducted from my account on the 5th of March.).
Dental Service Center reserves the right to refund or terminate electronic payment services. This agreement is to remain
in effect until Dental Service Center terminates it or receives written notification from the enrollee to terminate
participation in the plan and Dental Service Center has sufficient time to act upon the request.
You must
enroll for the
full plan year
through June 30, 2019
Send your
completed
enrollment
form(s) and
separate
check(s) by June 04, 2018
DENTAL PLAN APPLICATION
SELECT THE PLAN THAT’S RIGHT FOR YOU PLEASE PRINT
1. CIGNA PPO CIGNA HMO Please choose a dental office from the website
www.cigna.com or 1-800-244-6224. Dental Office Code No.__________
2. I am enrolling: Myself only Myself + One Myself + Family
LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW
Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________
Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.
Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
3. CHOOSE A PAYMENT OPTION – SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—Enclosed is my check to cover the first quarter’s premium for the option I selected above. I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken the 5th of each month prior to the following calendar quarter for which premiums is due. (For example the October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________ Authorized Signature for Automatic Deductions Date
4. I accept the coverage/insurance benefits provided by this group dental plan and authorize the processing of my enrollment in the dental coverage as indicated on this form. I authorize any participating dental office to release dental records and billing information to CIGNA Dental Health for purposes of plan administration.
5. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month
date. I must wait 2 years before I can re-enroll.
6. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date
DENTAL SERVICE CENTER
P. O. Box 3907, Gardena CA 90247-7599 Telephone (888) 293-4903
1. Original to Dental Service Center 2. Copy for your files
VISION CARE PLAN APPLICATION
SELECT THE COVERAGE TYPE THAT’S RIGHT FOR YOU PLEASE PRINT
1. I am enrolling: Myself only Myself + One Myself + Family
LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW
Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________
Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.
Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
2. PAYMENT OPTION - SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM
Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—I have enclosed a payment for the first quarter and I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken on the 5th of each month prior to the following calendar quarter for which premium is due. (For example October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________
Authorized Signature for Automatic Deductions Date
3. I accept the coverage/insurance benefits provided by this group vision plan and authorize the processing of my enrollment in the vision plan. I authorize any participating vision office to release vision records and billing information to VSP for purposes of plan administration. 4. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month date. I must wait 2 years before I can re-enroll. 5. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date
DENTAL SERVICE CENTER P. O. Box 3907, Gardena CA 90247-7599
Telephone (888) 293-4903 1. Original to Dental Service Center 2. Copy for your files