Unemployment Application - Excel by ato42904


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									                                             EMPLOYER GROUP APPLICATION
                                      Small Group: 2 - 9 Employer Paid / Non-Voluntary

ACH Form, Web & E-billing Authorization Form, and HIPAA
Certification must be included with the Employer Group                                       For Delta Dental internal use only
Application in order for this application to be considered
                                                                                         Group #
complete. A copy of the Unemployment Insurance Report of
Worker Wages must also be submitted. Incomplete                                     Subgroup #
applications may be returned.

              Please fill out/select from all yellow and green fields as applicable. Blue areas are reserved for Delta Dental.

                                                             Contact Information
Legal Group Name:
Street Address:
City, State, Zip:
Phone:                                                        FAX:

Salutation                      Click on field to select from list
Contact                                                       Title:
Phone:                                                        FAX:

If Billing is different from above, please complete below :
Is this a TPA?                               Select Yes or No to indicate if this is a Third Party Administrator
Billing Entity Name:
Billing Address:
City, State, Zip:
Contact                                                       Title:
Phone:                                                        FAX:

                                                        Eligibility and Enrollment
Select Product:                                                                                     Click on field to select from list
Note: EyeMed Vision Discount Plan included with all products

Total Number of Enrolled Employees                              Enter number
Total Number of Eligible Employees                              Enter number
NOTE: All full time employees are eligible.

Employee %                                                      Enter percent
Dependent %                                                     Enter percent

Unless otherwise indicated, all employees become eligible FOM following 3 months of hire,

Dependent Eligibility: Children to age 25 EOM, regardless of student status.

     Delta Dental Group App - SmGrp 2-9                               Revised 5/7/2009                                                    page 1
If all employees become eligible the first of the month (FOM)
following 3 months of hire, select "Yes":                                                     Click on field to select Yes or No

If "No", to match medical eligibility, please select one of the                               Click on field to select from list; leave blank if
following:                                                                                   above selection is "Yes"

Minimum number of hours worked per week to
establish eligibility:                                                                        Enter number of hours

Does your company cover same sex Domestic Partners?
                                                                                              Click on field to select from list

Enter name of previous dental carrier:                                                        Enter name

If internal transfer group from Delta
Dental, enter prior Delta Dental group                                                        If applicable, enter prior group number
NAICS (Industry Code)                                                      Enter number - must be completed by Broker or Employer


                                                                          Tier Structure #                              4
Payment Method:                           ACH                                                            RATES
                                                                          $                  Employee Only
Initial Enrollment Method:                Paper                           $                  Employee + Spouse
                                                                          $                  Employee + Children
Ongoing Enrollment                    Web Tool*                           $                  Employee + Family

               * Web (Employer Connection) enrollment requires additional forms for security purposes

Enrollment Type:                   Late Enrollment

Enrollment must be made within 31 days of becoming eligible or within 31 days of loss of coverage through another group dental plan.
Persons who do not enroll when initially eligible must be enrolled for 12 months before receiving benefits for services other than
diagnostic & preventive.
100% employer contribution for all eligible employees, and 100% of eligible employees must enroll.

                                              Contract Information and Signatures
Group Effective Date                                                                          Enter date (mm/dd/yyyy)

Benefit Period for deductibles and maximums:                        Calendar Year

Contract Period (number of months)                                     24 months

The first month's premium is estimated to be:                                 $

     Delta Dental Group App - SmGrp 2-9                           Revised 5/7/2009                                                        page 2
It is agreed that the Group Contract will not become effective unless and until this application is approved and accepted by
DeltaDental of Colorado.

It is understood that this application will be considered part of the Contract between Delta Dental of Colorado and the Group.

Account Executive                     Bruce Grider
Account Manager                        Sherl Stills

Authorized Signature for group                                              Delta Dental of Colorado Signature

Date                                                                        Date

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or
agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado division of insurance within the department of regulatory agencies.

                                                           Producer Information
Producer Name:
Producer Firm:
Street Address:
City, State, Zip:
Phone:                                                        FAX:

Do you currently receive commissions from Delta Dental?                                          Select Yes or No
If no, please complete and return Agent Agreement

TIN#                                                                         Enter number
E-commissions?                                   Select Yes or No

   Please send completed and signed Master Application including ACH Form, Web & E-billing Authorization Form, HIPAA Form,
  Employee Enrollment Forms, Prior Carrier bill if applicable, Tax and Wage Report and estimated first month's premium payment to:
                                                          Delta Dental of Colorado
                                               Sales and Marketing - Small Group Business Unit
                                                       4582 South Ulster Street Ste 800
                                                             Denver, CO 80237

     Delta Dental Group App - SmGrp 2-9                           Revised 5/7/2009                                                         page 3
                                      Automatic Draft Authorization (ACH)
                                    Please print or type when completing this form.

             Purpose of Authorization (please indicate one)

                          New Authorization

                          Changes to Existing Authorization
                          (Note: Changes will be completed within 30 days of receipt date)

             Name of Company
             Group Number
             City, State, Zip

Contact Name
Phone Number                                                Fax No
E-mail Address
Name of Depositor

Preferred to the to Receive Summary Invoice
In additionMethodsummary invoice, do you wish               FAX                    E-mail
to receive a complete eligibility list each month?          YES                    NO

                              For Self-funded Groups Only
The automatic draft applies to:                       Administrative Fees Only
                                                      Claims Payment Only
                                                      Administrative Fees & Claims Payment

             I (We) hereby authorize DELTA DENTAL OF COLORADO hereinafter called “COMPANY”,

             Type of Account:                               Checking                           Savings

             Name of Financial Institution
             Transit/ABA No
             Account No

             This authority is to remain in full force and effect until COMPANY has received notification

             Authorized on behalf of
             Printed Name

                           Fax this form to (303) 221-4457, ATTN: Accounts Receivable

                                                                                             ACH Rev Mar 2007 pkz
                                                Delta Dental of Colorado
                                            Group Health Plan Certification

             The                                                 Group Health Plan (Plan) does hereby certify
      to the following:

 1    That the Plan is a “group health plan” within the meaning of the Health Insurance Portability and Accountability Act
      of 1996 (HIPAA).

      That the Plan documents you distribute to employees informing them about their benefits or the Plan documents
 2    you are legally required to maintain for your employee benefits plans (such as ERISA Plan documents) have been
      amended, as required by 45 CFR §164.504(f) and §164.314(b) HIPAA, to incorporate the following provisions and
      you, as the Plan Sponsor (employer) agreed to:

    Not use or further disclose health information protected under HIPAA (Protected Health Information (PHI)) other
    than as permitted or as required by law;
    Ensure that any agents, including subcontractors, to whom you provide PHI agree to the same restrictions and
    conditions that apply to you with respect to such information;
2c. Not use or disclose PHI for employment-related actions and decisions;
    Report to Plan’s designee any PHI use or disclosure that you become aware of that is inconsistent with the uses or
    disclosures provided for;
2e. Make PHI available to an individual based on HIPAA’s access requirements;
    Make PHI available for amendment and incorporate any PHI amendments based on HIPAA’s amendment
2g. Make available the information required to provide an accounting of disclosures;
    Make internal practices, books and records relating to the use and disclosure of PHI received from the Plan
    available to the Secretary of Health and Human Services to determine the Plan’s compliance with HIPAA;
    Ensure that adequate separation required by HIPAA 45 CFR §164.504(f)(2)(iii) is supported by reasonable and
    appropriate security measures;
    If feasible, return or destroy all PHI received from the Plan that you, as the Plan Sponsor, still maintain in any form
2j. and retain no copies of such PHI when no longer needed for the specified disclosure purpose. If return or
    destruction is not feasible, you will limit further uses and disclosures to those purposes that make the return or
    destruction infeasible;
    Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the
2k. confidentiality, integrity, and availability of the electronic protected health information that it creates, receives,
    maintains, or transmits on behalf of the group health plan;

2l. Ensure that any agent, including a subcontractor, to whom it provides this information agrees to implement
    reasonable and appropriate security measures to protect the information; and
2m. Report to the group health plan any security incident of which it becomes aware.

 3    The undersigned further certifies that he or she has the authority to sign on behalf of the Plan.

                  Printed Name of Plan Representative                                   Delta Dental Group Number

                    Signature of Plan Representative                                               Date

      Delta Dental of Colorado puts a high priority on compliance with laws and regulations under which it operates and
      is dedicated to protecting the information of our enrollees.

      Group Number:
                                                                                           Website & E-Billing Authorization Form
                                                                                                       Small Groups (under 100)
Purpose: This form allows a Plan Sponsor to: (1) open Website Accounts for authorized individuals and business associates for purposes
of submitting enrollment information and obtaining access to bills; and (2) request that Delta Dental of Colorado (DDCO) send bills via e-
mail. Please complete all fields that are shaded in yellow.

                                                    Plan Sponsor Requesting Authorization
Group Name:                                                                  Group Number:


E-mail Address:                                                            Telephone:

Complete one form for each employee requiring access. Provide user name, e-mail, and phone number for the individual and identify the
access authorized for that individual by checking the box next to the service. Please also supply a key word in the event a password is
forgotten (applicable only for those requiring a password).

Check the appropriate box below
         Add User                      Terminate User

User Name:
                                                          Phone Number:
Key Word (choose one):

Last 4 digits of SSN:                                      Pet Name:                                  Mother's Maiden Name:

The group, acting through its undersigned representative, certifies that the individual identified above is authorized to access the checked
websites below and perform the functions associated with each website on the group’s behalf and hearby authorizes DDCO to open a
website account for the individual set forth above (access requires password).

Check the appropriate box(es) below to indicate approved access:

         Receive bills via e-mail                                                                   View Only - bills

         Submit, modify and view enrollment data                                                    View Only - enrollment data                              (cannot
                                                                                                    make changes or updates)

In consideration for the privileges set forth in this Website Account and E-Billing Authorization form, the group, acting through its Group Administrator
hereby agrees to the following conditions:
1. DDCO may rely on electronically submitted enrollment data to the same extent as if submitted by non-electronic means;
2. Group will undertake reasonable measures to safeguard account information, including user name and password, and to prevent unauthorized access
to the website by someone acting or purporting to act on the group’s behalf;
3. All requests to close the Website Account, or stop the receipt of bills via e-mail must be submitted via e-mail to employerconnect@ddpco.com, or
faxed to 303.741.4233. DDCO shall have three business days (excluding holidays) to process such requests;
4. Group shall be solely responsible for any liability arising from the use of the Website Account or receipt of bill via e-mail and shall indemnify, hold harmless
and defend DDCO against any claim arising from the Authorized User’s use of the Website Account, practice of sending bills via e-mail or the groups failure
to safeguard account information, including, but not limited to, errors and omissions and violations of state and federal privacy laws; and
5. The individual signing this application form has the authority to permit the requested access and bind the group to the terms and conditions set forth above.

  Group Adminstrator:                                                                                                Date:

Delta Dental Group Implementation Check List
Delta Dental makes every effort to have a smooth and efficient new group setup. Our processes serve to provide the member with timely eligibility so they
have no delays in seeking the dental care they need. Please submit new cases with correct and completed documentation by the 25 of the preceding

                          Completed the Master Application (please include the forms located in the tabs at the bottom of the Master Application document)

                          Enrollment Forms
                          Employer Connection Authorization form (required for 2-9 plans and all groups wanting to provide eligibility via the website)
                          Automated Clearing House Authorization form (required for 2-9 plans)

                          HIPPA Form
                          Copy of Prior Carrier Bill (if applicable to takeover credits)
                          Copy of Tax and Wage Report or Schedule C (for 2-9 plan options only)
                          Estimated 1st month premium (group implementation will be delayed if not received with the above listed documentation)

Mail completed forms to:
                             Delta Dental of Colorado
                             Attn: Small Group Sales
                             4582 S. Ulster Street, Suite # 800
                             Denver, CO 80237

Small Groups with 2-9 enrolled employees can print ID Cards at www.deltadentalco.com. The member must register first and then will be able to print the
card. Employers who have access to the secured area of the website will also be able to print ID Cards.

Group Premium Calculation (Optional)
To calculate the estimated first month premium for your group:
 1. Fill in the rates for plan chosen on the table below.
 2. Multiply rates by the number of employees in each membership category to determine total monthly premium. This amount is due with your application

                             Number                           Rate                         Monthly
                            Employees                                                      Premium
         Employee Only                            x                           =
     Employee/Spouse                              x                           =
                                                  x                           =

       Employee/Family                            x                           =
No Coverage/ coverage
           elsewhere                              x                           =

      Total Amount Due

Please submit all documents and estimated 1st month premium payment by the 25th of the preceding month.

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