Sold Case Requirements

Golden West Dental & Vision Sold Case Requirements Checklist

Prepaid Group Plan

	Group Master Application, completed and signed by an officer of the company.
	Employee Enrollment Cards. Be sure to have member complete name, Social Security #, dentist office selected (if applicable), and all dependents to be covered.
	Binder check equal to first month's premium.
	Confirmation of plan design, rates sold, Golden West proposal, and effective date of plan.
	Agent Licensing Agreement (if first case with Golden West).

Indemnity/PPO

	Group Master Application, completed and signed by an officer of the company.
	Completed enrollment forms, including waivers.
	Binder check equal to first month's premium.
	Copy of prior carrier bill and benefits booklet or certificate of coverage, if takeover benefits apply.
	Authorization For Release of Information, if takeover benefits apply.
	Agent Licensing Agreement (if first case with Golden West), plus U.S. Life Agent Profile form.

Individual Plan

	Enrollment card. Be sure to have member complete name, Social Security #, dentist office selected (if applicable), and all dependents to be covered.
	Fill in Agent Number on enrollment card.
	Check for monthly, semi-annual, or annual rate. Applications for monthly payment plan require payment of two months' rate at initial enrollment. (Rates are printed in the individual plan brochures.)
	Agent Licensing Agreement (if first case with Golden West).

Please note: Individual Plan enrollment must be received by the 20th of the month for a first of the next month effective date.

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