Personal Dental Insurance Coverage          Freedom to choose Dentist or use Preferred Provider Network          Over ...
Benefits Summary                Dental Benefits                                PLAN 1                     PLAN 2          ...
Plan Features                                                                    TERMINATION OF COVERAGEELIGIBLE EXPENSES ...
ADDITIONAL DENTAL EXPENSES NOT COVERED UNDER                                        ADDITIONAL DENTAL EXPENSES NOT COVERED...
Product PortfolioDN11Careington Maximum Care Dental Network (PPO, CPPO & Dentemax)Careington has owned and managed dental ...
Security Life Insurance                                                PPO Plus Dental Plans  PPOCompany of America       ...
Security Life Insurance Company of America, Minnetonka, MN                                                         PPO Plu...
Page 2 of 2                                     PPO PLUS DENTAL PLANS                    PREMIUM RATE CALCULATION AND AUTH...
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PPO Dental Plus - Standard Brochure

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Introducing the most innovative and affordable dental plan on the market today. This unique "hybrid" plan design allows applicants to purchase the benefits they want and need, not those they may never use. Premiums are extremely competitive and priced far below traditional indemnity or PPO plans. Go to ppodentalplus.com for complete details and one life rates.

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PPO Dental Plus - Standard Brochure

  1. 1. Personal Dental Insurance Coverage  Freedom to choose Dentist or use Preferred Provider Network  Over 197,000 network provider locations nationwide  No waiting periods on preventive care benefits  Three plans to choose from  Plans for ages 65+  Prices you can afford!           Dental Network provided by:  www.PPODentalPlus.com     Underwritten by:Security Life insurance Company of America Marketed by: 10901 Red Circle Drive  Minnetonka, MN 55343Policy GH-1112-40130 AIGILISForm S11132 (11-11)
  2. 2. Benefits Summary Dental Benefits PLAN 1 PLAN 2 PLAN 3Initial & Periodic Exams * 100% 100% 100%(Two per calendar year)  (Insured Benefit) (Insured Benefit) (Insured Benefit)X-Rays including Bitewing* 100% 100% 100% (Insured Benefit) (Insured Benefit) (Insured Benefit)Cleaning * 100% 100% 100%(Two per calendar year) (Insured Benefit) (Insured Benefit) (Insured Benefit)Fluoride Treatments to age 16 * 100% 100% 100%(One per calendar year) (Insured Benefit) (Insured Benefit) (Insured Benefit) 100% 100% 100%Space Maintainers* and Sealants to age 14* (Insured Benefit) (Insured Benefit) (Insured Benefit) 80% 80% Non-insured BenefitFillings (Insured Benefit) (Insured Benefit) PPO Discount Only 3 month waiting period 3 month waiting period 80% 80% Non-insured BenefitSimple Extractions (Insured Benefit) (Insured Benefit) PPO Discount Only 3 month waiting period 3 month waiting period Non-insured Benefit 50% Non-insured BenefitOral Surgery PPO Discount Only (Insured Benefit) PPO Discount Only 12 month waiting period 50% Non-insured Benefit Non-insured BenefitEndodontics (Insured Benefit) PPO Discount Only PPO Discount Only 12 month waiting period 50% Non-insured Benefit Non-insured BenefitPeriodontics (Insured Benefit) PPO Discount Only PPO Discount Only 12 month waiting period 50% Non-insured Benefit Non-insured BenefitCrowns (Insured Benefit) PPO Discount Only PPO Discount Only 12 month waiting period 50% Non-insured Benefit Non-insured BenefitBridges (Insured Benefit) PPO Discount Only PPO Discount Only 12 month waiting period 50%Dentures Non-insured Benefit Non-insured Benefit (Insured Benefit) PPO Discount Only PPO Discount Only 12 month waiting periodOrthodontics Non-insured Benefit Non-insured Benefit Non-insured Benefit PPO Discount Only PPO Discount Only PPO Discount OnlyCosmetic Dentistry  Implants Non-insured Benefit Non-insured Benefit Non-insured Benefit  Veneers PPO Discount Only PPO Discount Only PPO Discount Only  Resin fillingsMaximum Insured Benefit $ 500 per person $ 750 per person $ 1,500 per personMaximum PPO Discount Benefits No Maximum No Maximum No MaximumDeductible None 50 Ind/150 Family Max 50 Ind/150 Family Max*Deductible waived for this service regardless of plan selection.Important information: After annual maximum for insurance stops and for treatments not covered by the insurance policy, the planwill continue to provide discounted services through our Preferred Provider Network (PPO). This is because the PPO negotiated fees willapply to give a continued savings even after the insured benefits are exhausted. Please check with your Dental Provider for discountsavailable.
  3. 3. Plan Features TERMINATION OF COVERAGEELIGIBLE EXPENSES Coverage terminates on the earliest of the following dates: (a) the lastWe will pay for Eligible Expenses You Incur for Yourself or on behalf of day of the month in which You cease to be eligible for coverage; (b) theYour Insured Dependent. Expenses must be incurred while the Policy is last day of the month in which Your Dependent is no longer a dependentin force and the person is covered by the Policy. The description of as defined; (c) subject to the Grace Period, the last day of the month forEligible Expenses is shown in the Coverage Schedule. To be an Eligible which a premium has been paid by you or on your behalf; (d) or the dateExpense, the dental service or procedure must be performed by a the Master Policy ends.Dentist, a Physician or a Dental Hygienist. EFFECTIVE DATEEXPENSES INCURRED You and Your Dependents are covered on the later of: the date WeAn Eligible Dental Expense is considered incurred on the following dates: accept Your enrollment and determine an effective date; or the date YouFor full and partial dentures – the date the final impression is taken; for first acquire a Dependent, if the date is after Your coverage begins.fixed bridges, crowns, inlays and onlays – the date the teeth are firstprepared; for root canal therapy – the date the pulp chamber is opened; REASONABLE AND CUSTOMARYfor periodontal surgery – the date surgery is performed; for all other Reasonable and Customary means the usual, customary and regularservices – the date the service is performed. charges for the area where such expenses are incurred.DEDUCTIBLE AMOUNTThe calendar year Deductible, if any, is shown in the Coverage DENTAL EXPENSES NOT COVEREDSchedule. The Deductible is an amount of eligible charges you must ‐ for overdentures and associated procedures;incur for Yourself or on behalf of Your insured Dependent(s) before we ‐ for charges in excess of those considered Reasonable andcan begin paying benefits. Customary; ‐ for cosmetic procedures;CALENDAR YEAR MAXIMUM ‐ for the replacement of dentures, bridges, inlays, onlays or crowns thatThe maximum limit payable for all Eligible Expenses in any calendar year can be repaired or restored to normal function;is shown in the Coverage Schedule. The Maximum Calendar Year Limit, ‐ for implants and for replacement of lost or stolen appliances,if any, will apply to each person covered under the Policy. replacement of retainers, athletic mouthguards, precision or semi-PRETREATMENT REVIEW precision attachments, denture duplication;If the Course of Treatment will exceed the amount shown in the ‐ for oral hygiene instructions, and for: plaque control, completion of aCoverage Schedule, We will request prior review. We must be given the claim form, acid etch, broken appointments, prescription or take-homeDentist’s treatment plan consisting of a description of the planned fluoride, or diagnostic photographs;treatment with estimated charges and diagnostic x-rays. We will ‐ for services not completed by the end of the month in which coveragedetermine Eligible Expenses and state how much We will pay for the ends unless continuation of coverage has been requested andtreatment. Our determination may suggest an alternate, less expensive accepted by Us;Course of Treatment if it will produce professionally satisfactory results. If ‐ for procedures that are begun, but not completed;You do not request a pretreatment review, We will pay for the least ‐ for services and treatment provided without charge, or for which thereexpensive method of treatment regardless of the method actually used. would be no charge in the absence of insurance; ‐ for services in connection with war or any act of war, whether declaredCOORDINATION OF BENEFITS or undeclared, or condition contracted or accident occurring while on(Does not apply in Maine, Maryland and South Dakota) This Plan will be full-time active duty in the armed forces of any country or combinationcoordinated with any other group, blanket or franchise plan under which of countries;an Individual will receive benefits. ‐ for a condition covered under any Worker’s Compensation Act orALTERNATE BENEFIT similar law;If: 1) We determine that a less expensive alternate procedure, service or ‐ that are applied toward satisfaction of a Deductible, if any;Course of Treatment can be performed in place of the proposed ‐ that are generally considered by the dental profession as experimentaltreatment to correct a dental condition; and 2) the alternative treatment or investigational;will produce a professionally satisfactory result; then the maximum We ‐ for the treatment of cleft palate and anodontia;will allow will be the charges for the less expensive treatment. ‐ for services or supplies payable under any medical expense plan; ‐ for orthodontia, unless included within the Coverage Schedule;MISSING TOOTH ‐ prior to the date the Insured is covered under the Policy;When covered under your plan, benefits are provided for placement of ‐ for the diagnosis or treatment of Temporomandibular Joint Dysfunctiondentures, fixed bridgework, implants or the addition of teeth to existing (TMJD);dentures only when the service includes replacement of a natural tooth ‐ for hospital services;extracted or lost while covered under this plan. This limitation ends after ‐ if you voluntarily end your insurance You will not be eligible to re-enrollthe individual receiving care has been covered under this plan for 36 for a period of 2 years after the date Your coverage first ended;consecutive months. ‐ charges for infection control, sterilization, and waste disposal.ELIGIBILITYIndividuals, 18 years of age or older, plus their eligible dependents(spouse and unmarried children from birth to age 26). This is subject toindividual state regulations.
  4. 4. ADDITIONAL DENTAL EXPENSES NOT COVERED UNDER ADDITIONAL DENTAL EXPENSES NOT COVERED UNDERPLAN 2—Discount Benefits Only PLAN 1 – Discount Benefits OnlyIf you select Plan 2 the following expenses are not covered in addition to If you select Plan 1 the following expenses are not covered, in addition tothose listed above in ―Dental Expenses Not Covered All Plans - those listed under Plan 2, and ―Dental Expenses Not Covered AllDiscount Benefits Only. Plans—Discount Benefits Only- for oral surgery, including postoperative care. - for crown build-ups.- for endodontic treatments. - for recementing inlays, onlays, crowns and bridges.- for periodontic services. - for repair of dentures or bridges. -- for restoration services.- for study models. - for prosthetic services. -for fillings; - for simple extractions; - for antibiotic injections IMPORTANT FRAUD NOTICES Any person who knowingly presents a false or fraudulent claim for payment at a loss or benefit or knowingly presents false information in an application forinsurance is guilty of a crime and may be subject to fines and confinement in prison.Colorado application for insurance is guilty of a crime and may be subject to civilIt is unlawful to knowingly provide false, incomplete, or misleading facts fines and criminal penalties.or information to an insurance company for the purpose of defrauding or Ohioattempting to defraud the company. Penalties may include Any person who, with intent to defraud or knowing that he is facilitating aimprisonment, finds, denial of insurance and civil damages. Any fraud against an insurer, submits an application or files a claiminsurance company or agent of an insurance company who knowingly containing a false or deceptive statement is guilty of insurance fraud.provides false, incomplete, or misleading facts or information to a policy Pennsylvaniaholder or claimant with regard to a settlement or award payable from Any person who knowingly and with intent to defraud any insuranceinsurance proceeds shall be reported to the Colorado division of company or other person files an application for insurance or statementinsurance within the department of regulatory agencies. of claim containing any materially false information, or conceals, for theDistrict of Columbia purpose of misleading, information concerning any fact material theretoWARNING: It is a crime to provide false or misleading information to an commits a fraudulent insurance act, which is a crime and subjects suchinsurer for the purpose of defrauding the insurer or any other person. person to criminal to and civil penalties.Penalties include imprisonment and/or fines. In addition, an insurer may Tennessee/Virginiadeny insurance benefits if false information materially related to a claim It is a crime to knowingly provide false, incomplete or misleadingwas provided by the applicant. information to an insurance company for the purpose of defrauding theFlorida company. Penalties include imprisonment, fines and denial of insuranceAny person who knowingly and with intent to injure, defraud, or deceive benefits.any insurer files a statement of claim or an application containing anyfalse, incomplete, or misleading information is guilty of a felony of the IMPORTANT NOTICE:third degree.Kentucky This brochure provides a very brief description of some importantAny person who knowingly and with intent to defraud any insurer or other features of your Plan. It is not the Insurance Contract nor does itperson files an application for insurance containing any materially false represent the Contract. A full explanation of benefits, exceptions andinformation or conceals for the purpose of misleading, information limitations is contained in the Certificate of Insurance Policy Form GH-concerning any fact material thereto commits a fraudulent insurance act 1112-40130 issued to the Voluntary Group Trust for all states except forwhich is a crime. Maine, Maryland and South DakotaMaineIt is a crime to knowingly provide false, incomplete or misleading A full explanation of benefits, exceptions and limitations is contained ininformation to an insurance company for the purpose of defrauding the the Group Dental Insurance Policy form GH-1112(ME-IND) for Maine,company. Penalties may include imprisonment, fines or a denial of GH-1112(MD-IND) for Maryland and GH-1112(SD-IND) for Southinsurance benefits. Dakota.New JerseyAny person who includes any false or misleading information on an Aigilis Dental Plan may not be available in all states.application for an insurance policy is subject to criminal and civilpenalties. No agent has the authority to change any benefits, to bind coverage withNew Mexico Security Life Insurance Company, or to promise a certain effective date.Any person who knowingly presents a false or fraudulent claim forpayment of a loss or benefit or knowingly presents false information in an Underwritten by: Security Life Insurance Company of America - 10901 Red Circle Drive - Minnetonka, MN 55343
  5. 5. Product PortfolioDN11Careington Maximum Care Dental Network (PPO, CPPO & Dentemax)Careington has owned and managed dental networks for 30 years and has recently contracted with DenteMax,another quality dental network provider, to create a “combined” national PPO dental network with significantpresence. This combined network is known as the Maximum Care Network.The Maximum Care Network consists of over 197,000 credentialed dental access points contracted to providedental services at reduced rates nationwide. The network combines the outstanding network managementskills of two great organizations and results in average aggregate discounts of 5% to 50% below the 80thpercentile of Reasonable and Customary charges.Members are able take advantage of savings offered by leaders in the dental care industry.  Sample Savings Description * Regular Cost ** Plan Cost Savings Adult Cleaning $114 $60 48% Child Cleaning $79 $43 45% Routine Checkup $64 $30 53% Four Bitewing X-rays $74 $39 47% Composite (White) Filling $175 $97 44% Crown (porcelain fused to noble metal) $1,301 $740 43% Complete Upper Denture $1,763 $968 45% Molar Root Canal $1,270 $710 44% Extraction (single tooth) $219 $100 55% * Regular cost is based on the average of the 80th percentile usual and customary rates as detailed in the Ingenix Report for 2010 in Los Angeles, Orlando, Chicago and New York City. ** These fees represent the average of Careingtons MaximumCare Series fee schedule in Los Angeles, Orlando, Chicago and New York City. Prices subject to changeAbout Careington: Careington International Corporation is a Discount Medical Plan Organization and PPODental Network Administrator that provides access to quality dental, health care and lifestyle services atreduced rates. The company provides a range of membership programs that deliver significant savings to morethan seven million members nationwide.About DenteMax: DenteMax was founded in 1985 in Michigan. DenteMax eventually expanded into Ohio andCalifornia, and gradually throughout the entire United States to become the nation’s largest leasable dentalPPO network.This is a PPO plan. This is not a discount plan.Third party administrators will pay for covered services according to the plan design. All applicable co-pays, deductibles orco-insurance, outlined by the plan design, are to be paid directly to the dental office at the time service is rendered.Please ask the dentist or office staff to explain all charges before treatment begins.
  6. 6. Security Life Insurance PPO Plus Dental Plans PPOCompany of America Monthly Rates effective January 1, 2012 through September 1, 2012 effective dates Rates are guaranteed for the initial 12 months of coverage. Once covered, premiums are likely to increase on a semi-annual basis. Rate Chart Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8 Single $ 17.02 $ 18.34 $ 20.11 $ 22.10 $ 24.31 $ 26.74 $ 29.39 $ 32.27 Plan 1 Single Plus One $ 31.24 $ 33.67 $ 36.92 $ 40.57 $ 44.63 $ 49.09 $ 53.96 $ 59.23 UNDER AGE 65 Family $ 50.46 $ 54.39 $ 59.63 $ 65.53 $ 72.08 $ 79.29 $ 87.15 $ 95.67 Single $ 25.44 $ 27.42 $ 30.07 $ 33.04 $ 36.34 $ 39.98 $ 43.94 $ 48.24 Plan 2 Single Plus One $ 47.19 $ 50.87 $ 55.77 $ 61.29 $ 67.42 $ 74.16 $ 81.52 $ 89.48 Family $ 76.58 $ 82.54 $ 90.50 $ 99.45 $ 109.40 $ 120.33 $ 132.27 $ 145.20 Single $ 34.13 $ 36.79 $ 40.34 $ 44.33 $ 48.76 $ 53.64 $ 58.96 $ 64.72 Plan 3 Single Plus One $ 63.66 $ 68.62 $ 75.23 $ 82.67 $ 90.94 $ 100.03 $ 109.95 $ 120.70 Family $ 103.53 $ 111.60 $ 122.36 $ 134.46 $ 147.91 $ 162.70 $ 178.83 $ 196.31 Single $ 18.72 $ 20.18 $ 22.12 $ 24.31 $ 26.74 $ 29.42 $ 32.33 $ 35.49 Plan 1 Single Plus One $ 34.37 $ 37.04 $ 40.61 $ 44.63 $ 49.09 $ 54.00 $ 59.36 $ 65.16 Family $ 53.25 $ 57.39 $ 62.93 $ 69.15 $ 76.07 $ 83.67 $ 91.97 $ 100.96 65 AND OVER Single $ 27.98 $ 30.16 $ 33.07 $ 36.34 $ 39.97 $ 43.97 $ 48.33 $ 53.06 Plan 2 Single Plus One $ 51.91 $ 55.96 $ 61.35 $ 67.42 $ 74.16 $ 81.58 $ 89.67 $ 98.43 Family $ 84.24 $ 90.80 $ 99.55 $ 109.40 $ 120.34 $ 132.37 $ 145.50 $ 159.72 Single $ 37.55 $ 40.47 $ 44.37 $ 48.76 $ 53.64 $ 59.00 $ 64.85 $ 71.19 Plan 3 Single Plus One $ 70.02 $ 75.48 $ 82.76 $ 90.94 $ 100.03 $ 110.04 $ 120.95 $ 132.77 Family $ 113.89 $ 122.77 $ 134.60 $ 147.91 $ 162.70 $ 178.97 $ 196.72 $ 215.95 Zip Code Chart State State State State State State State Zip Area Zip Area Zip Area Zip Area Zip Area Zip Area Zip Area Alabam a Colorado Illinois (Cont.) Maryland Montana Oklahom a (Cont.) Texas 350-351 1 801 5 605-608 4 206 4 590 2 750-751 4 354-355 1 802 4 611 3 207-209 5 592-597 2 743-745 1 752-753 5 359 1 808-809 5 619 1 210-211 4 599 2 747-749 1 760-763 3 360-361 1 816 4 624-626 1 214 4 All Other 3 All Other 2 770 4 362-364 1 All Other 3 628 1 219 4 Oregon 772-773 4 367-368 1 Connecticut All Other 2 All Other 3 Nebraska 978-979 2 774-775 3 All Other 2 065-066 6 Indiana Massachusetts 680 1 All Other 3 786-787 4 Alaska 068-069 7 462-464 3 010-011 4 683-684 1 Pennsylvania All Other 2 995-997 6 All Other 5 All Other 2 012 3 686-693 1 157-158 1 Utah All Other 5 Delaw are Iow a 013-015 5 All Other 2 164-165 1 842-847 1 Arizona 197-198 5 504-508 1 020 5 Nevada 168 1 All Other 2 850 4 All Other 3 512-517 1 023 5 893-895 4 179 1 Verm ont 852 4 Dist. Colum bia 521 1 024 7 897-898 4 180-181 3 Not Available All Other 3 All Areas 5 All Other 2 027 4 All Other 3 182 1 Virginia Arkansas Florida Kansas All Other 6 New Ham pshire 188 1 Not Available 716-721 1 Separate Rate Sheet 661-662 3 Michigan Not Available 189-191 4 Washington 723-724 1 Georgia 664-665 1 484-485 2 New Jersey 193-194 4 Not Available 728 1 301-302 4 667-669 1 488-499 2 Not Available All Other 2 West Virginia All Other 2 303 5 670-671 1 All Other 3 New Mexico Rhode Island 260 1 California 307 2 673-679 1 Minnesota 870 3 029 4 265 1 902-908 5 310 2 All Other 2 550 3 871 4 All Other 2 All Other 2 913 5 311 5 Kentucky 551 4 873-875 3 South Carolina Wisconsin 919-921 5 312 2 403-404 1 553-555 4 877 3 293 2 530-532 3 926,928 5 316-319 2 407-409 1 561-562 1 884 3 295 2 534 3 931 7 398 2 411-418 1 All Other 2 All Other 2 All Other 3 543 4 932-934 3 All Other 3 425-427 1 Mississippi North Carolina South Dakota All Other 2 935 5 Haw aii All Other 2 386 1 Separate Rate Sheet Plan 1 Only Wyom ing 939-940 5 All Areas 3 Louisiana All Other 2 North Dakota All Areas 2 All Areas 2 941 6 Idaho 701 3 Missouri Separate Rate Sheet Tennessee 943-944 6 Not Available All Other 2 630-631 3 Ohio 370-371 3 945-951 5 Illinois Maine 633-634 3 450-451 3 372 4 All Other 4 601 4 039-041 5 635-639 1 456 3 379 3 602-603 4 044 4 641 3 All Other 2 382-384 1 604 3 046 4 644-647 1 Oklahom a All Other 2 048 4 653-655 1 734-735 1 (Cont.) All Other 3 All Other 2 (Cont.) S11155 PPO Plus 11-11
  7. 7. Security Life Insurance Company of America, Minnetonka, MN PPO Plus Dental Plans MAIL - the application along with initial payment to: Aigilis Dental Plans P.O. Box 953279 Lake Mary, FL 32795 Page 1 of 2Plan Selection:  Plan 1  Plan 2  Plan 3  Under age 65  Age 65 or Older I apply for coverage on:  Single Only  Single + 1  FamilyAPPLICANT INFORMATION (PLEASE PRINT CLEARLY)Last Name First Name Initial Birth Date / /Address Telephone Number Sex: MFCity State Zip Marital StatusBilling Address (If Different) City State Zip Married  Single LIST ALL YOUR ELIGIBLE DEPENDENTS BELOWLast Name (If Different) First Name Initial Sex M/F Age Birth DateSpouse / /Dependent / /Dependent / /Dependent / /Does Spouse have a dental plan: Yes  No  With Whom? _________________________________________________________________If answer is “Yes”, are dependents enrolled under spouses plan? Yes  No  IMPORTANT FRAUD NOTICESAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in anapplication for insurance is guilty of a crime and may be subject to fines and confinement in prison.Colorado - It is unlawful to knowingly provide false, incomplete, or New Jersey - Any person who includes any false or misleadingmisleading facts or information to an insurance company for the purpose information on an application for an insurance policy is subject to criminalof defrauding or attempting to defraud the company. Penalties may and civil penalties.include imprisonment, fines, denial of insurance and civil damages. Any New Mexico - Any person who knowingly presents a false or fraudulentinsurance company or agent of an insurance company who knowingly claim for payment of a loss or benefit or knowingly presents falseprovides false, incomplete, or misleading facts or information to a policy information in an application for insurance is guilty of a crime and may beholder or claimant with regard to a settlement or award payable from subject to civil fines and criminal penalties.insurance proceeds shall be reported to the Colorado division of Ohio - Any person who, with intent to defraud or knowing that he isinsurance within the department of regulatory agencies. facilitating a fraud against an insurer, submits an application or files aDistrict of Columbia - WARNING: It is a crime to provide false or claim containing a false or deceptive statement is guilty of insurancemisleading information to an insurer for the purpose of defrauding the fraud.insurer or any other person. Penalties include imprisonment and/or fines. Pennsylvania - Any person who knowingly and with intent to defraud anyIn addition, an insurer may deny insurance benefits if false information insurance company or other person files an application for insurance ormaterially related to a claim was provided by the applicant. statement of claim containing any materially false information, orKentucky - Any person who knowingly and with intent to defraud any conceals, for the purpose of misleading, information concerning any factinsurer or other person files an application for insurance containing any material hereto commits a fraudulent insurance act, which is a crime andmaterially false information or conceals for the purpose of misleading, subjects such person to criminal and civil penalties.information concerning any fact material thereto commits a fraudulent Tennessee/ Virginia - It is a crime to knowingly provide false, incompleteinsurance act which is a crime. or misleading information to an insurance company for the purpose ofMaine – It is a crime to knowingly provide false, incomplete or misleading defrauding the company. Penalties include imprisonment, fines andinformation to an insurance company for the purpose of defrauding the denial of insurance benefits.company. Penalties may include imprisonment, fines or a denial ofinsurance benefitsIMPORTANT INFORMATION Effective Date – The effective date is the first of the month following the day in which the application is received in the Service CenterOffice. Identification Card and Certificate of Insurance - Upon receipt of your completed application you will receive a copy of your Certificate ofInsurance and Identification Card(s). Do not cancel any other dental coverage you may have until you receive written confirmationfrom Security Life. Please allow 3-4 weeks for processing.By my signature below, I hereby apply for coverage under Group Dental Insurance Policy GH-1112-40130 issued to the VoluntaryGroup Trust. I also certify I have read the applicable Fraud Notice above. California Law prohibits an HIV Test from being required or used by health insurance companies as a condition of obtaininghealth insurance coverage.Applicant Signature______________________________________________________________________________ Date_____________________________ Please refer to the reverse side for payment options and agent informationGHA-1112 S11123 (STD) 8-11
  8. 8. Page 2 of 2 PPO PLUS DENTAL PLANS PREMIUM RATE CALCULATION AND AUTHORIZATION AGREEMENT The following sections must be completed and signed by the applicant and agent MODE OF PAYMENT Select your mode of payment  Monthly – Bank Account Debit (ACH) (Checking or Savings) Complete Authorization Agreement below and submit one (1) month premium Checking Acct. - Attach voided check - DO NOT SUBMIT DEPOSIT SLIP. Savings Acct. - Attach savings deposit slip with account number including the bank routing number.  Monthly Credit Card - Complete Authorization Agreement Select One  Visa  Master Card Card # __________________________________________________ Expiration Date _______/____/______ Monthly Rate (Locate the first 3 digits of your zip code on the Zip Code Area Enter Initial payment on Chart. Using the corresponding area number, determine Total Monthly Bank draft and Credit Card applicable monthly premium found on the Rate Chart based Premium under Total Monthly Premium upon your eligibility age, plan selection and coverage type Zip Code: $ Applications received in the Service Center Office by the 20th of the month will become effective the first day of the following month. For Initial payment, make check payable to Security Life Insurance Company of America AUTHORIZATION AGREEMENT: (When paying by ACH or Credit Card please complete the section below) As a convenience to me, I authorize Security Life Insurance Company of America/Meritain Health to initiate debit entries to my bank account or credit card account for my monthly dental premium. I understand this will occur by the third business day of each month and that such record will appear on my monthly statement. I agree that if any such charge be dishonored, whether with or without cause and whether intentionally or inadvertently, the bank or credit card company shall be under no liability whatsoever even though it might result in forfeiture of my insurance. I understand that this agreement will remain in effect until Security Life Insurance Company of America has received written notice from me that it should be cancelled. I understand that I have the right to stop payment by notification to Security Life Insurance Company of America, my bank or my credit card company at least ten business days prior to the next scheduled payment. ____________________________________________________ _______________ ___________________________________________________ Account Holder’s Name Date Account Holder’s Signature FOR AGENT USE ONLY – Please Print Clearly Producer Name Producer Phone # Street Address City St Zip Producer Email Producer SS#/TIN# Appointed with Security Life?  Yes  No Producer SignatureFOR COMPANY USE ONLY Effective Date: ______/______/______ Plan Code: _________________GHA-1112

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