WCOA Dental Benefit Enrollment
Please provide the following information:
First Name Last Name Middle Initial Street Address Address (cont.) City State/Province Zip/Postal Code Home Phone Social Security Number
Social Security Number
Date of Birth -- mm-dd-yy Gender Male Female
Email Address
Requested Effective Date: -- mm-dd-yy
**This does not guaranteed a specific effective date. Your final effective date will be determined by when a completed application is received and a full month's premium has been collected.
Do you have previous Coverage Yes No
I Choose to Enroll in the Dental Program
Yes No
Plan Enrolling In:
Supplemental Dental Plan 1 Supplemental Dental Plan 2 Economy Dental/Eye Care Plan Value Dental/Eye Care Plan 100/80/50 Dental Plan
Supplemental Dental Plan 1
Supplemental Dental Plan 2
Economy Dental/Eye Care Plan
Value Dental/Eye Care Plan
100/80/50 Dental Plan
I wish to enroll (Ameritas Dental Program):
Member Only Member Plus 1 (Child or Spouse) Member Plus 2 or more
DO YOU HAVE ELIGIBLE DEPENDENTS (INCLUDING SPOUSE)?
Spouse: Relation:
Date of Marriage -- mm-dd-yy
Gender: Male Female Spouse Birthdate: -- mm-dd-yy
Child(ren)'s Name Relation Gender Birthdate Full Time Student M F -- mm/dd/yy Yes No M F -- mm/dd/yy Yes No M F -- mm/dd/yy Yes No M F -- mm/dd/yy Yes No M F -- mm/dd/yy Yes No M F -- mm/dd/yy Yes No
Child(ren)'s Name Relation Gender Birthdate Full Time Student
M F -- mm/dd/yy Yes No
Any Additional Children?
If the address of any child is different than the member's address, please show that child's name and address below:
If requesting coverage for dependent child other than a son or daughter, please forward legal papers.
Total Monthly Premium:
Monthly Dental Premium: Click here to view Dental plans and premiums
Monthly Dental Premium:
Click here to view Dental plans and premiums
PAYMENT OPTIONS (Choose One):
*There is a 4% service fee for this option
Visa - Monthly *There is a 4% service fee for this option MasterCard - Monthly *There is a 4% service fee for this option Account #: -- (#### - #### - #### - ####) Expiration Date: mm-yy Name as it appears on the card: *An example of deductions is as follows: January’s premium will be deducted around December 20th for Credit Cards.
Visa - Monthly *There is a 4% service fee for this option MasterCard - Monthly *There is a 4% service fee for this option
Account #: -- (#### - #### - #### - ####)
Expiration Date: mm-yy
Name as it appears on the card:
*An example of deductions is as follows: January’s premium will be deducted around December 20th for Credit Cards.
To participate in this plan, Associate Membership in the Wisconsin Retired Educators’ Association (WREA) is required. Membership dues of $1.67 monthlywill be added to the above rates. By signing at dating below you do hereby enroll in the Ameritas Group Dental and/or EyeCare plan along with becoming an Associate Member of the WREA.
Insured Signature:
Please type your name the second time below for the confirmation of your signature.
Date Signed: -- mm-dd-yy
By completing & submitting this internet form you are applying for the WCOA Dental Benefits Program. Your credit card will be charged for the appropriate monthly premium.
Cancellations are requested in writing, mailed to Greater Insurance Service Corp. at 414 Atlas Ave, Madison, WI 5714-3165 OR faxed to( 608) 221-0868. Cancellation request must include: your name (please print), your policy number, requested cancellation date, and signature. Cancellation date will be the later of your requested date or the first of the month after written notice is received.