Massachusetts State Health Care Professionals’ Dental Fund

Reason for submission (Check all that apply) *

Open Enrollment New Hire Change Coverage Selection Add Dependents Listed Below Change of Address Change of Marital Status Change of Name

Please select the plan you wish to enroll (Check one box only) *

Standard Dental Plan (Fully paid by your employer) High Option Dental Plan (Refer to Payroll Deduction Authorization Section)

Employee SSN *

Sex *

Employee DOB *

Marital Status *

Employment Date *

Employee Name: Last (as shown on your paystub)

First (as shown on your paystub)

MI

Home Address (Street, Apartment Number) *

City *

State *

Zip *

Home Phone Number

Cell Phone

Email Address *

Spouse Name

Sex

Spouse SSN

Spouse DOB

The Fund and the Employee agree that this form may be electronically signed and that the electronic signature appearing on this form is the same as handwritten signatures for purposes of validity, enforceability and admissibility.

Print Name *

Signature *

Signed Date *

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT WHICH IS A CRIME.