aMERITAS

Enrollment Kit - Ameritas (dental)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.

Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Ameritas’ case submission requirements.

Selling Group Dental, Vision, LASIK and Hearing Benefits from the Brochure

  • Completed Ameritas Group Master Application​ signed by Employer and Agent.
  • Ameritas First Group Dental, Vision, LASIK and Hearing Options - Group Plan Selection Form
  • Ameritas Employee Enrollment form completed and signed by each person enrolling (minimum of 3 enrolled lives per
  • If the employer elects to pay for LASIK and Hearing Coverage, employees who enroll in a Dental or Vision plan will be enrolled in the LASIK and Hearing plan selected by the employer (minimum of 10 or more enrolled lives in an Ameritas Dental or Vision plan required)

Submitting a Group with “Takeover” Benefits:

  • All of the above plus a copy of the prior carrier’s benefits.
  • ​​​​​​​Copy of the takeover quote, if quoted.
 

Documentation Requirements:

  • Ameritas Group Master Application​** (signed by Agent and Officer of group).

  • Ameritas First Group Dental, Vision, LASIK and Hearing Coverage - Group Plan Selection Form**

  • Enrollment information completed for each enrollee - Ameritas Employee Enrollment Form or Ameritas Census File.

  • Waiver of coverage on back of the Ameritas enrollment/change/waiver form signed by employee when declining coverage

  • A check for the first month premium.

  • A copy of the prior carrier’s benefits* (required for all plans).

  • A copy of the quote, if applicable.​

* Only required when selling “takeover.”

 

** When submitting new business online, simply retain signed copies of the Group Master Application and Ameritas First Group Plan Selection Form for your records​.


IMPORTANT
A $15 monthly administration fee will apply.
The fee will be waived if the group elects to pay by electronic funds transfer and accepts online billing.
Group must register online at https://www.ameritas.com/service/register.asp.

 

Licensing: ​Broker appointment must be completed. The group will not be approved until licensing is received.

After approval, prior carrier termination letter must be submitted by the employer or broker.​
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For other useful or older documents, please refer to the Forms database. 

  • Appointment Application
    • Ameritas

    • form # N/A

    • Effective date: 03.01.2016

  • Enrollment / Change / Waiver - Dental Only
    • Ameritas

    • form #GR 875

    • Effective date: 04.01.2017

  • Group Master Application - Eff. 1/1/2018
    • Ameritas

    • form #GR 902

    • Effective date: 01.01.2017

  • Enrollment/Change/Waiver Form - Vision
    • Ameritas

    • form #GR 875

    • Effective date: 04.01.2017

  • Enrollment/Change/Waiver Form - Dental & Vision
    • Ameritas

    • form #GR 875

    • Effective date: 08.01.2016

  • Group Plan Selection Form
    • Ameritas

    • form # N/A

    • Effective date: 02.01.2021

  • New Group Submission Checklist
    • Ameritas

    • form # N/A

    • Effective date: 08.01.2020