Dergalis - Agent Benefitsdocs.agentbenefits.net/bairdwarner/dentalbairdwarner.pdf · Full and...
Transcript of Dergalis - Agent Benefitsdocs.agentbenefits.net/bairdwarner/dentalbairdwarner.pdf · Full and...
Group Enrollment Processing
In order to ensure proper processing of your applications, please read the following instructions carefully.
1) Once you have selected the plan(s) in which you wish to enroll, print and complete thecorresponding application(s).
2) Make sure you have signed and completed the application(s) in their entirety. Check them forany errors or missing information.
3) Review, complete and sign the Automatic Deduction Agreement form.
4) Make a photocopy of your voided check for the account from which you would like the premiumdeduction to take place and include it with your forms. Remember, all bank account deductionswill take place on the 1st business day of each month. If we are unable to draft your account onthis day, you may be subject to fees as outlined in the Automatic Deduction Agreement.
5) Email your application with the Automatic Deduction Agreement and the voided check [email protected]. We MUST have all applications by the posted due date orcoverage cannot become effective!
Please call us with any questions you have during the enrollment process.
Group InsuranceBenefi ts Administrator
P: (888) 564-0300, toll freeF: (856) 396-3193E: [email protected]
DergalisASSOCIATES
Email all finished paperwork to: [email protected]
Q: Must I take all of the benefits? A: No, each benefit can be purchased individually.
Q: Will I get another opportunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group
Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results.
Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program?
A: Yes, you will have the oppor tunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office.
Q: Is the Automatic Deduction from my checking account the only way to pay? A: Please contact our office at (888) 564-0300 for more information. Additionally, you can use a savings account
as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number. Please note, we are not set up for individual billing and cannot accept a check as payment.
Q: When and how will I receive confirmation of my coverage? A: You should receive an email from our office within three weeks. Please make sure to check your junk mail
folder if you haven’t received the email.
Q: What if I have an emergency before I receive proof of coverage?A: In the event of an emergency situation, you should contact
Someone will help in the transition period.
Q: Why am I not receiving email communication from the group insurance
A: The domain agentbenefits.net may be filtered out by some e-mail providers as “SPAM”. Please ensure to update your email address and communication preferences.
Frequently Asked Questions
Group Insurance at (888) 564-0300.
department?
The Lincoln National Life Insurance Company 1
The Lincoln DentalConnect® PPO Plan:
Covers many preventive,
basic, and major dental care
services
Also covers orthodontic
treatment for children
Features group rates for Bairdand Warner Sales Associates
Lets you choose any dentist
you wish, though you can
lower your out-of-pocket
costs by selecting a network
provider
Does not make you and your
loved ones wait six months
between routine cleanings
Full-Time Sales Associates of Baird and Warner
Benefits At-A-Glance
In-Network Out-of-Network
Calendar (Annual) Deductible
Individual: $50
Family: $150
Waived for: Preventive
Individual: $50
Family: $150
Waived for: Preventive
Deductibles are combined for basic and major In-Network services. Deductibles are combined for basic and major Out-of-Network services.
Annual Maximum $1,500 $1,500
Annual Maximums are combined for preventive, basic, and major services.
Lifetime Orthodontic Max
$1,500 $1,500
Orthodontic Coverage is available for dependent children.
Waiting Period There are no benefit waiting periods for any service
types
Visit LincolnFinancial.com/FindADentist
You can search by:
●Location
●Dentist name or office name
●Distance you are willing to travel
●Specialty, language and more
Your search will automatically provide up to 100 dentists that most
closely match your criteria. If your search does not locate the dentist you
prefer, you can nominate one—just click the Nominate a Dentist link and
complete the online form.
Dental Insurance
$48.90 $110.18 $116.05 $116.05 $142.43
1/1/2020 - 4/30/2021
Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA
2
Preventive Services In-Network Out-of-Network
Routine oral exams
Bitewing X-rays
Full-mouth or panoramic X-rays
Other dental X-rays (including periapical films)
Routine cleanings
Fluoride treatments
Space maintainers for children
Sealants
Biopsy and examination of oral tissue (including brush biopsy)
Labs & other tests
100%
No Deductible
100%
No Deductible
Basic Services In-Network Out-of-Network
Problem focused exams
Palliative treatment (including emergency relief of dental pain)
Injections of antibiotics and other therapeutic medications
Fillings
Prefabricated stainless steel and resin crowns
Simple extractions
Surgical extractions
Oral surgery
General anesthesia and I.V. sedation
Prosthetic repair and recementation services
Periodontal maintenance procedures
Non-surgical periodontal therapy
80%
After Deductible
80%
After Deductible
Major Services In-Network Out-of-Network
Consultations
Endodontics (including root canal treatment)
Periodontal surgery
Bridges
Full and partial dentures
Denture reline and rebase services
Crowns, inlays, onlays and related services
Build-ups/post & core
TMJ
Implants & implant related services
Occlusal guard
50%
After Deductible
50%
After Deductible
Orthodontics In-Network Out-of-Network
Orthodontic exams
X-rays
Extractions
Study models
Appliances
50% 50%
Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA
3
In-Network/Out-of-Network Dentists In-Network Out-of-Network
To find an in-network dentist near you, visit
www.LincolnFinancial.com/FindADentist.
This plan lets you choose any dentist you wish. However, your
out-of-pocket costs are likely to be lower when you choose an in-
network dentist. For example, if you need a crown…
…you pay a deductible (if applicable), then 50% of the remaining discounted fee for PPO members. This is known as a PPO contracted fee.
… you pay a deductible (if applicable), then % of the usual and customary fee, which is the maximum expense covered by the plan. You are responsible for the difference between the usual and customary fee and the dentist’s billed charge.
This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this
summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made
available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a
difference between this summary and the contract, the contract will govern.
Lincoln DentalConnect® health center Web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group®
company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.
Insurance products (policy series GL11) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business
in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Network access plans for specific states are located
on LincolnFinancial.com under the Forms section. Limitations and exclusions apply.
©2018 Lincoln National Corporation LCN-2012491-013118 R 1.0
Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA
4
Lincoln DentalConnect® Online Health Center Determine the average cost of a dental
procedure
Have your questions answered by a
licensed dentist
Find a dentist based on your home or
workplace location (or even your primary
language)
Get directions to your dentist’s office
Learn all about dental health for children,
from baby’s first tooth to dental
emergencies
Take an in-depth look at dental health
recommendations for seniors
Evaluate your risk for oral cancer,
periodontal disease, and tooth decay
Check your claim status
Print an ID card
Switch between English and Spanish
versions in just one click
Covered Family Members
When you choose coverage for yourself, you can also provide coverage for:
• Spouse
• Dependent children, up to age 26.
Benefit Exclusions
Like any insurance, this dental insurance plan does have some exclusions.
The plan does not cover services started before coverage begins or
after it ends. Benefits are limited to appropriate and necessary
procedures listed in the policy, along with any procedures required
by state law. Benefits are not payable for duplication of services.
Covered expenses will not exceed the policy’s allowances.
Plan benefits are not payable for a condition that is covered under
Workers’ Compensation or a similar law; that occurs during the
course of employment or military service or involvement in an illegal
occupation, felony, or riot; or that results from a self-inflicted injury.
The plan does not cover an orthodontia treatment plan started
before coverage begins unless the member was receiving
orthodontia benefits from the employer’s previous group dental
policy. In this case, Lincoln Financial will continue orthodontia
benefits until the combined benefit paid by both policies is equal to
this policy’s lifetime orthodontia maximum. Plan benefits are not
payable if the orthodontic appliance was installed after the age of 19.
In certain situations, there may be more than one method of treating
a dental condition. This policy includes an alternative benefits
provision that may reduce benefits to the lowest-cost, generally
effective, and necessary form of treatment.
Certain conditions, such as age and frequency limitations, may
impact your coverage. See the plan policy for details.
This plan includes continuation of coverage for Sales Associates with
dental coverage from a previous employer. The member is required
to complete the Continuity of Coverage form located on
www.lfg.com. The form must be provided to us prior to the effective
date to be eligible for continuation of coverage.
A complete list of benefit exclusions is included in the policy. State variations apply.
DergalisASSOCIA TES
HOME ADDRESS
SS #
FIRST
COMPANY NAME OFFICE LOCATION
DENTAL VISION
A. PLEASE CHECK ALL COVERAGE(S) YOU ARE APPLYING FOR
PHONE
CITY
I represent that all information supplied in the application is true and correct. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime.
STATE
BIRTH DATE
HIRE DATE
GENDER
ZIP
M F
ADMINISTRATIVE USE ONLY
EFFECTIVE DATE
Applying for single coverage for myself Applying for myself and dependents listed below
B. PLEASE INDICATE WHO WILL BE INSURED UNDER THE POLICY (CHECK ONLY ONE)
SPOUSECoverage for:
Dental Vision Both
CHILD 1Coverage for:
Dental Vision Both
CHILD 2Coverage for:
Dental Vision Both
CHILD 3Coverage for:
Dental Vision Both
C. ENROLLMENT INFORMATION (COMPLETE IF INCLUDING COVERAGE FOR DEPENDENTS)
GENDER
GENDER
GENDER
GENDER
FIRST
SS#
SS#
SS#
SS#
BIRTH DATE
BIRTH DATE
BIRTH DATE
BIRTH DATE
SIGNATURE DATE
M F
M F
M F
M F
Dental and Vision Insurance Enrollment Form
OCCUPATION
Page 1 of 3
SIGNATURE REQUIRED
MI
MI LAST NAME
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
LAST
FIRST MI LAST NAME
FIRST MI LAST NAME
FIRST MI LAST NAME
Realtor
SIGNATUREof account owner*
SIGNATUREof insured
*Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions.
Revised 8/6/2019
DATE
DATE
Automatic Deduction and Notification AgreementPLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING:
I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates, to access my account for the
dental, vision, life, and / or disability insurance premiums. I understand that these deductions will be made periodically and I realize that changes in premiums may result in higher or lower deductions. I further understand that I shall incur additional charges in the event this debit is returned for any reason. In the event that Realty Benefits Servicesthe month, I will be charged $25.00. I understand there is no monthly paper billing from Realty Benefit Services, an affiliate of Dergalis Associates and I cannot pay by check.
SOCIAL SECURITY # EMAIL
HOME PHONE
HOME ADDRESSCITY STATE ZIP
CELL PHONE
REALTY COMPANY OFFICE LOCATION
NotificationsI agree to provide signed written notice at least two weeks in advance in the event I wish to cancel, change or amend my current policies. I further agree to indemnify and hold harmless Realty Benefit Services, an affiliate of Dergalis Associates, for charges assessed on my account from my lending institution due to debits for services rendered. I agree to notify Realty Benefit Services, an affiliate of Dergalis Associates, in writing of any changes to my bank account. This notice will be at least two weeks in advance of any scheduled payment debits. (You can email your notice to Dergalis Associates at to [email protected].)
I understand that these services are being provided solely through arrangements with Realty Benefit Services, an affiliate of Dergalis Associatesthat I must notify Dergalis Associates in writing if I no longer work as a licensed Realtor or become a
notify Dergalis Associates within 30 days of my termination, I realize I may continue to get billed for
NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS ASSOCIATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY. I understand that any changes to or termination of my coverage will also affect the coverage I have elected for my dependents.
By signing, I acknowledge that I have read and accept the terms of the above notification agreement.
NAME OF INSURED
WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) YES NO
IF YES, WHO:
Page 2 of 3
SIGNATURE REQUIRED
Co-Signature is required if the insured is not listed on the checking account .
Page 3 of 3
Attach Voided Check
Attach Your Business Card
DergalisASSOCIATES