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AU T H O R I Z E D U S E O N LY
Policy Group Numbers:
708788
Plan Variation/Reporting Code:
Dental and Vision Benefits
ALLSTATE BENEFITS ACCIDENT
Underwritten by American Heritage Life Insurance Company
Please complete mail, fax or email form to:
Pierce Insurance Agency, Inc., ATTN: NCRS
P.O. Box 727, Farmville, NC 27828
email: [email protected]
PVRC 0001-0001
PVRC 0002-0002
PVRC 0003-0003
PVRC 0004-0004
PVRC 0005-0005
PVRC 0006-0006
Dental Plan Code: P3271
Group Accident Account Number: 15934
Effective Date:
Phone: 1-855-627-3847 Fax: 1-252-753-5941
A C C I D E N T , D E N TA L , A N D V I S I O N E N R O L L M E N T F O R M
SOCIAL SECURITY N U M B E R:
DATE OF RETIREMENT
LAST NAM E:
FI RST NAM E:
/
/
(Month/Day/Year)
M.I.:
ENROLL
ADDRESS CHANGE
CANCEL
DATE OF CHANGE:
/
CHANGE
NAME CHANGE
/
(Month/Day/Year)
E M PLOYE E’S DATE OF B I RTH:
ADDR ESS:
STATE:
CITY:
Z I P:
MALE
FEMALE
SINGLE
MARRIED
ACCIDENT COVERAGE Underwritten by American
Heritage Life Insurance Company
DENTAL COVERAGE
Underwritten by United Healthcare Insurance Company
PLAN 1:VISION EXAM & MATERIALS PLAN COVERAGE
Underwritten by United Healthcare Insurance Company
PLAN 2: VISION MATERIALS ONLY PLAN COVERAGE
Underwritten by United Healthcare Insurance Company
/
/
HOME TELEPHONE NUMBER:
(
)
EMAIL ADDRESS:
BENEFICIARY NAME:
RELATIONSHIP
TO INSURED:
YES
NO
YES
NO
YES
YES
LOW PLAN
(Month/Day/Year)
......
HIGH PLAN
SPOUSE
CHILD
SIBLING
OTHER
RETIREE
RETIREE + SPOUSE
RETIREE + CHILD(REN)
IF YES, CHECK COVERAGE:
RETIREE
RETIREE + ONE (1)
RETIREE + FAMILY
NO
IF YES, CHECK COVERAGE:
RETIREE
RETIREE + ONE (1)
RETIREE + FAMILY
NO
IF YES, CHECK COVERAGE:
RETIREE
RETIREE + ONE (1)
RETIREE + FAMILY
FAMILY
I N F OR MATI ON FOR DE P E N DE NT C OV E RAG E
Spouse & Unmarried Dependent Children Only (Include Date of Birth)
First Name
M.I. Last Name
(if different)
M/F Date of Birth
(Month/Day/Year)
M
F
/
Relationship If child is over Enroll in:
age 26, please
indicate status
/
Wife
Husband
Child
/
Wife
Husband
Child
/
Wife
Husband
Child
/
Wife
Husband
Child
/
Wife
Husband
Child
Handicapped
SOCIAL SECURITY N U M B E R:
M
F
/
Handicapped
SOCIAL SECURITY N U M B E R:
M
F
/
Handicapped
SOCIAL SECURITY N U M B E R:
M
F
/
Handicapped
SOCIAL SECURITY N U M B E R:
M
F
/
Handicapped
SOCIAL SECURITY N U M B E R:
Dental
Vision
Dental/Vision
Accident
Change
Cancel
Other Dental Insurance:
Dental
Vision
Dental/Vision
Accident
Change
Cancel
Other Dental Insurance:
Dental
Vision
Dental/Vision
Accident
Change
Cancel
Other Dental Insurance:
Dental
Vision
Dental/Vision
Accident
Change
Cancel
Other Dental Insurance:
Dental
Vision
Dental/Vision
Accident
Change
Cancel
Other Dental Insurance:
CARRIER NAME
CARRIER NAME
CARRIER NAME
CARRIER NAME
CARRIER NAME
For court-ordered dependents, documentation must be attached.
I confirm that the information I have provided on this form is complete and accurate. Any person who knowingly and with intent to injure, defraud or deceive any
insurer, files a statement of claim or an application containing any false, incomplete or misleading information may be prosecuted as allowed by appropriate state law.
Payroll Deduction Authorization — This section must be signed and dated to receive benefit.
I hereby authorize the North Carolina Retirement Systems to deduct my dental, vision and/or accident plan premiums from my retirement benefit period.
To the best of my knowledge, I confirm that the information I have provided on this form is complete and accurate.
SIGNATURE
NCRS-01
DATE
The UnitedHealthcare Dental plan is administered by Dental Benefit Providers, Inc.
The UnitedHealthcare Vision plan is administered by Spectera, Inc.