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This is an enrollment option for you to select dental insurance for you and your family. If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources.

Superior Dental 2010 Enrollment

*Your Email Address:

If you do not have an email address to insert in the previous question, please insert the following email address: employee@cicl.com

To accurately process your decision, it is necessary for you to complete this form in its entirety and do not leave any questions unanswered. If a question does not apply to your decision, place the letters "NA" for your answer and proceed to the next question until completed.

Would you like to select dental coverage (Y/N):

   * First Name:

   *

Middle Initial:

   * Last Name:

   * SS#:

   * Street Address:

   * City:

   * State:

   * Zip:

   * Home Phone #:

   * Work Phone #:

   *

Gender (M/F):

   * Date of Birth (month/date/year):

   *                                     Decline Participation

I do not wish to select this coverage.

Dependent Coverage Identification:

If you selected this coverage, please provide the following dependent information. Dependent information is the list of family members that will be covered under this insurance. Please list the following information for each dependent.

1. Full Name of each dependent

2. Their relationship to you

3. The dependents sex (M/F)

4. Date of Birth of each dependent

If you selected coverage, please provide the following information. If you did not select this coverage, place "NA" as you answer.

Is your spouse employed? (Y/N):

If you selected coverage, please provide the following information. If you did not select this coverage, place "NA" as you answer.

Does your spouse carry any other type of dental coverage? (Y/N):

If you selected to participate in the dental coverage plan, please provide the:

1. Name of the Insurance Company

2. Name of your spouses employer

3. Employer address

4. Your spouses SS#

5. The policy group #

6. The name(s) of the covered individuals.

Employee Electronic Signature:

I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request. I authorize CICL to make the necessary deductions from my compensation to pay the premium when my insurance becomes effective. I undertstand that my payroll deduction amount will change if my coveage or costs change.

My employee number and the last four digits of my SS# are: (111111/2222)