Please print this form    WOLFPACK  DELTA CARE APPLICATION, Employer List Bill Agent Information:      I.D. #
Mail to: Wolfpack Insurance Services, Inc.    800-296-0192  CA License # 0814789 Agent Name:
Small Business Benefit Plan Trust Plan Agent Address:
P. O. Box 156  Belmont CA 94002 Agent Phone #
DeltaCare from PMI Dental Health Plan

This is a dental HMO Program.  You and your family must receive all treatment from the DeltaCare dental office you select. 

Please indicate the number of the DeltaCare office you have chosen: #_________________

Provider Name ___________________________________________________________
 
Rates
Enrollment type Monthly List Bill Members Rates through December 2007           Rates Effective January 1, 2008
One Person $29.60                                                         $30.30
Two Persons $52.20                                                         $52.50
Three Persons or more $76.80                                                         $78.60
      Employer list bill: Please include the monthly premium for all enrollees, a $5.00 enrollment fee for each member and a $5.00 billing fee.

            Employer Name:__________________________________________  
           
            Employer address ___________________________________________________________  City______________________  State: California  Zip Code:___________________

            Employer Contact: ________________________________________    Employer Phone Number: _____________________________________
 

Enrollee Social Security Number:___________________________
  First Name Last Name

Male or Female

Date of Birth
Enrollee        
Spouse        
Child        
Child        
Child        
Child        

I hereby understand and acknowledge that I am enrolling in the Wolfpack Insurance Services Trust group for DeltaCare coverage under group 01675, plan 11B.  Benefit and plan information was reviewed from the DentalandVisionIns.com web site, Family Plan Section.  I agree to the terms and conditions of the plan.
Click here to view a complete evidence of coverage for this plan.  

We will send you a copy of the Evidence of Coverage for Plan 11B along with a wallet card for your use as confirmation that you are enrolled.
The minimum enrollment period is 12 months.  Should you voluntarily cancel enrollment and subsequently desire to re-enroll, all premiums retroactive to the date of cancellation (but not to exceed 12 months) must be paid before you can re-enroll.

Premium rates renew January 1st of each year and I understand that I will be sent a renewal notice to the last known address on Wolfpack Insurance Services systems.  I hereby authorize my medical or dental care institution or professional to release to a representative of PMI, any personal, privileged or medical records information including, but not limited to, my patient records, charts, x-rays, diagnosis histories, billing records, clinical abstracts, or copies of consultations.  The information authorized herein may be used for determination of benefits, quality assessment, utilization review, grievance resolution. or investigation or compliance with the PMI provider agreements or local, state or federal laws.  This authorization is valid for the duration of coverage.

Signature of enrollee ____________________________   Date _____________________________

Note: The enrollment information must be received at the latest by the 15th of the month for coverage to begin the 1st of the following month. Incomplete. inaccurate information will cause a delay in your enrollment into the program.