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Forms and Literature For your convenience, Securian Dental provides web site access to forms needed by group administrators below. Check back in the future as we add additional forms, brochures, applications and more. The following documents can only be viewed by using Acrobat® Reader® software, which can be downloaded free of charge from www.adobe.com. General Information Reference Manual for Group Administrators - all states except VT, ME, NH Membership Enrollment and Maintenance Membership Enrollment Form (for all states except the following) Membership Enrollment Form - Spanish Membership Maintenance Form (for all states except the following) New Group Enrollment Checklist (VT, ME, NH) Disabled Dependent/Michelle's Law Application Billing Automated Clearinghouse (ACH) Authorization Agreement Billing Reports Online User Request Form Billing Reports Online Change Request Form Group Premium Billing Schedule International/Expatriate Emergency Program International Dental Emergency Program Brochure International Expatriate Dental Program Brochure Claim Form and Instructions for Members International Dentist Nomination Form COBRA Premium Subsidy COBRA Election Form for groups with less than 20 full-time employees. (Please note: This form does not apply to groups based in AL, AK, AZ, DE, HI, ID, IN, MI, MT, PA, or VA as these states do not have laws that provide for continuation of coverage for groups of fewer than 20 employees.) |
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