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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