Slappey and Sadd, LLC - 2025 Benefits Guide

C. Coverage selection – (Top boxes for employer and Aetna use only.)

Control/Group number

Suffix

Account

Plan number

1. Dental

Yes No

To enroll, enter the plan number and name below.

Non-voluntary plans – Plan number

Plan name

®

or

PPO

If FOC, check:

DMO

Voluntary plans – Plan number

Plan name

®

If FOC, check:

DMO

or

PPO

Before today, were you covered under this employer’s dental plan? Yes

No

Creditable coverage is allowed for new members enrolling in voluntary takeover groups. New hires please see below if applicable:

New Hire selecting a Voluntary plan and your Aetna plan is a takeover group : Were you covered for 12 months under a dental plan within the

last 90 days that included both Preventive and basic coverage? Discount dental and preventive only plans do not apply.

Yes No

Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO ®

service area to be eligible to enroll

in the DMO ® .

Aetna Health Inc. underwrites the Aetna DMO ®

dental plans. Aetna Life Insurance Company underwrites all other Aetna dental plans.

Control/Group number

Suffix

Account

Plan number

SM

Preferred

Yes No

2. Aetna Vision

Aetna Life Insurance Company underwrites Aetna vision plans. First American Administrators, Inc. provides certain claims administration services.

EyeMed Vision Care, LLC (“EyeMed”) provides certain network administration services.

D. Individuals covered – List individuals for whom you are enrolling or adding, changing or removing coverage. Add more sheets if needed.

Employee name (Last, first, middle initial)

Sex (M/F)

Add

1

Change

Remove

Birthdate (MM/DD/YYYY)

Status

Choosing coverage for:

Single

Married

Divorced

Dental

Vision

/

/

Widowed

Legally separated

Dental provider office ID number

Current patient

Yes

Sex (M/F) Social Security number

Name (Last, first, middle initial)

Add

Spouse

Domestic partner

2

Change

Remove

Birthdate (MM/DD/YYYY)

Choosing coverage for:

/

/

Dental

Vision

Dental provider office ID number

Current patient

Yes

Sex (M/F) Social Security number

Name (Last, first, middle initial)

Child

Stepchild

Add

Other

3

Change

Remove

Birthdate (MM/DD/YYYY)

Handicapped

Choosing coverage for:

Yes No

Dental

Vision

/

/

Dental provider office ID number

Current patient

Yes

Continued on next page

7000-2-SG

7000-2 (6-18)

2

SG (1-50) GA V2 B

12 | Slappey & Sadd, LLC 2025 Benefits Guide

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