Golden West Dental & Vision Membership Enrollment Form

Please fill out the information in the form below. Fields noted with an asterisk (*) are required.

I wish to enroll in the Dental and Optometric Plan. I understand that all necessary services will be provided as described in the Principal Benefits and Coverages Copayment Schedule. Premium payment can be made by Visa or Mastercard when using online enrollment.

Personal Member Information

First Name*	Initial	Last Name*

Social Sec. #*		Date of Birth* (mm/dd/yyyy)

Address*


City*	State	Zip*
	CA

Mailing Address (if different)


City	State	Zip
	CA

Home Phone*	Work Phone	E-mail Address*

Gender*		Marital Status

Plan Type:*

Provider Selection

First Choice*
Dental Office Code # *		Dental Office Name


Second Choice
Dental Office Code #		Dental Office Name

Eligible Dependent Information

1. Spouse

First Name		Last Name

Date of Birth	Gender	Full-time Student
		Yes No

Dental Office Code #		Dental Office Name

2. Child

First Name		Last Name

Date of Birth	Gender	Full-time Student
		Yes No

Dental Office Code #		Dental Office Name

3. Child

First Name		Last Name

Date of Birth	Gender	Full-time Student
		Yes No

Dental Office Code #		Dental Office Name

4. Child

First Name		Last Name

Date of Birth	Gender	Full-time Student
		Yes No

Dental Office Code #		Dental Office Name



A. PLAN will not end the membership of a DEPENDENT who is a child upon reaching age 19 if he or she is incapable of self-sustaining employment because of mental retardation or physical handicap. PLAN may require proof of his or her incapacity and dependency. The SUBSCRIBER must provide that proof within 31 days of request by PLAN. If the child is age 21 or older, PLAN will not request this information more than once each year. B. PLAN will not end the membership of DEPENDENT who is a child upon reaching age 19 if he or she is a full-time student at an accredited secondary school, trade school, college, or university. PLAN may require proof of his or her full-time status. "Full-time status" means the child is taking courses for at least 12 credit hours in each academic period. The SUBSCRIBER must provide that proof within 31 days of request by PLAN. A full-time student may continue as a MEMBER even if he or she lives outside the SERVICE AREA. PLAN will not continue membership for a full-time student after age 23.

If you have more dependents, please email us your social security number and the name of dependent, date of birth, relationship, and dental office selection.
Maximum of three offices per family.

Method of Payment

I hereby authorize Golden West Dental & Vision to charge my account each month for the applicable Plan premium to be credited to my account with Golden West. This authority is to remain in force and effect until I notify Golden West Dental & Vision in writing of its termination. My banking institution is authorized to make corrections if necessary.