California Dental network

enrollment kit - california dental network (dental)

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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 California Dental Network’s case submission requirements​
 
  • Application for Group Coverage - Employer Applicati​on (DHMO)​.
  • Census Enrollment Sheet.
  • Employee Enrollment Forms – submit one enrollment form per enrollee.
    • Advantage Plan 75 Employee Enrollment Applicatio​n and Brochure
    • Advantage Plan 75 Employee Enrollment Applicatio​n and Brochure (Espanol) ​
    • Advantage Plan 100 Employee Enrollment Applicati​on and Brochure 
    • Advantage Plan 100 Employee Enrollment Applicati​on and Brochure (Espanol)​
    • Advantage Plan 150 Employee Enrollment Application and Brochure
    • Advantage Plan 150 Employee Enrollment Applicati​on and Brochure (Espanol)
    • Advantage Plan 200 Employee Enrollment Applicati​on and Brochure​
    • Advantage Plan 200 Employee Enrollment Applicati​on and Brochure (Espanol)​
    • Advantage Plan 250 Employee Enrollment Application and Brochure
    • Advantage Plan 250 Employee Enrollment Applicati​on and Brochure (Espanol)​
  • First month’s premium check made payable to “California Dental Network”.
  • Prior Carrier Invoice and Prior Carrier Benefit Summary, if applicable.
  • Copy of quote or copy of rates used to sell case.
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  • Broker Licensing: Agent Contract​​ and copy of license (if applicable).​​

​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.