Instructions for completing and printing
Form # 50650-1008R Rev. 1208
Application for BlueDental Choice PPO for Individual Insurance
This form can be completed online either through tabbing from field to field or using your
mouse to move from field to field. You must click your left mouse key to “check” the
boxes, as appropriate. Complete pages 1 and 2 of the form, print it out and sign it (on
both pages, if applicable). Depending on the payment method that you choose, include
the following with your application.
Payment by Bank Draft:
Send a voided check that includes the bank routing &
account numbers, complete all requested information and
sign/date authorization (Box 47). We will deduct your 1st
and future premiums from your account.
Payment by Check:
Include a check with your application and complete (Boxes
48, 49 and 50)
Payment by Credit Card:
Complete all requested information, and sign/date
authorization (Boxes 51-56)
Page two contains the Payment Information section. If this section is not complete, your
application (along with any payment) may be returned and your effective date will be
delayed.
When you have completed the application, mail it to:
FCL Membership and Billing
P.O. Box 37859
Jacksonville, Florida 32236
Due to software restrictions, you will not be able to save the completed form on your
computer unless you have Adobe Acrobat Professional software. If you make a mistake
and do not discover it until you have printed the form and exited the software, you may
make a hand-written correction; however, you must initial that change.
For more information and assistance, call our Direct Sales Center toll free at
888-753-4363.
22213-1208
APPLICANT COPY
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF INDIVIDUAL DENTAL INSURANCE
Florida Combined Life Insurance Company, Inc.
4800 Deerwood Campus Parkway, Bldg. 200, Suite 600
Jacksonville, Florida 32246
SAVE THIS NOTICE. IT MAY BE IMPORTANT TO YOU IN THE FUTURE
Please read this if you intend to lapse or otherwise terminate existing dental insurance and
replace it with a Florida Combined Life Insurance Company, Inc., individual dental insurance
policy. Your new policy provides 10 days within which you may decide without cost whether you
desire to keep the policy. For your information and protection, you should be aware of and
seriously consider certain factors, which may affect the insurance protection available to you
under the new policy.
1. Health conditions that you may presently have may not be immediately or fully covered under
the new policy. This could result in denial or delay of a claim for benefit under the new policy,
whereas a similar claim might have been payable under your present policy.
2. If you are replacing existing dental insurance, you may wish to secure the advice of your
present insurer or its agent regarding the proposed replacement of your present policy. This
is not only your right but is also in your best interest to make sure you understand all the
relevant factors involved in replacing your present coverage.
3. If, after due consideration, you still wish to terminate your present policy and replace it with
new coverage, read the copy of the application attached to your new policy and be sure all
questions are answered truthfully and completely. Omissions or misstatements in the
application could cause an otherwise valid claim to be denied. Carefully check the
application and write to Florida Combined Life within 10 days if any information is not correct
and complete.
Florida Combined Life Insurance Company, Inc.
50646-W-1209
Dental Replacement
Web Applicant
LIMITATIONS AND EXCLUSIONS
Limitations
1. Any retreatment of root canals are payable one (1)
year after completion date of root canal therapy.
2. Restorations made of amalgam, silicate, acrylic, and
composite materials to restore diseased teeth are
only payable on the same tooth surface once every
twelve (12) consecutive months.
3. The gingivectomy or gingivoplasty per quadrant
allowance will be paid when two or more teeth are
billed on the same date of service, same quadrant.
4. Sealants are limited to the first and second molars
for primary teeth and the bicuspids and molars for
the permanent teeth of dependent children.
5. General anesthesia and intravenous sedation is
payable only if given in connection with covered
surgical procedures.
6. Periodontal maintenance procedures following
active therapy is limited to two (2) times per plan
year. Periodontal prophylaxis will be subject to the
same limits as a routine prophylaxis. The total
benefit for prophylaxis is limited to two (2) times per
plan year.
7. Periodontal services are limited to insureds age
eighteen (18) and older.
8. Services performed outside the United States, its
territories and possessions are not covered, except
for palliative emergency treatment.
9. Multiple amalgam or composite restorations on one
surface will be considered one restoration. The
allowance includes insulating base and local
anesthesia.
Exclusions
The following are excluded under this policy:
1. Coverage for installation of an initial prosthodontic
appliance that replaces any teeth missing prior to an
insured's effective date of coverage.
2. Services or supplies which are not medically
necessary according to accepted standards of
dental practice, as determined by our consulting
dentists, or which are not recommended or
approved by the attending dentist.
3. Charges for services or supplies when billed by
other than a dentist.
4. Benefits for services rendered by a member of your
family, (your spouse and the child[ren], brothers,
sisters and parents of either you or your spouse).
5. Services rendered primarily for cosmetic purposes.
6. Charges incurred for failure to keep a dental
appointment.
16672-0307
7. Services rendered through a medical department,
clinic or similar facility provided or maintained by, or
on the behalf of, an employer, mutual benefit
association, labor union, trustee or similar persons
or groups.
8. Medical services related to the treatment of
temporomandibular joint (TMJ) (temporal bone lower jaw) dysfunctions (craniomandibular disorders,
craniofacial disorders).
9. Experimental or investigational treatment.
10. Dental services received or rendered:
a. through or in a veteran's hospital or government
facility due to a service connected disability;
b. which are covered and paid under Worker's
Compensation or similar law; or
c. which are coordinated with another insurance
policy providing dental benefits for the same
charges, to the extent that the total amount
payable under both plans exceeds 100% of the
FCL allowance for expenses actually incurred.
Services for which the insured incurs no charge.
11. Procedures, appliances, or restorations necessary to
alter vertical dimension and/or restore or maintain
the occlusion. Such procedures include, but are not
limited to, equilibration, periodontal splinting, full
mouth rehabilitation, restoration of tooth structure
lost from attrition and restoration for malalignment of
teeth.
12. Local anesthesia when billed separately by a dentist.
13. Any services paid or payable under the insured's
health insurance policy.
14. Services not listed in this policy or any schedules
attached to this policy.
15. Charges for a more expensive service, procedure, or
course of treatment than is customarily provided by
the dental profession, consistent with sound
professional standards of dental practice for the
dental condition concerned. Payment for such
charges under this policy will be based on the
allowance for the least costly service, procedure, or
course of treatment.
16. Any additional treatment required due to the
insured's failure to follow instructions, or lack of
cooperation with the dentist.
17. Treatment for any illness, injury, or medical
conditions arising out of: war or act of war (whether
declared or undeclared), participation in a felony, riot
or insurrection, service in the armed forces or
auxiliary units, and attempted suicide or intentionally
self-inflicted injury, whether sane or insane.
LIMITATIONS AND EXCLUSIONS
18. Services rendered before the effective date of
coverage.
19. Services rendered after termination of coverage,
except as provided under “Extension of Benefits
upon Contract Termination.”
20. Charges for services or supplies for sterilization.
Charges for sterilization are included in the
allowance for other covered dental procedures.
21. Any denture or bridge replacement made necessary
by reason of loss, theft, or alteration by an insured.
22. Services in connection with any crown, inlay or onlay
restoration, or for any denture or bridge if treatment
began prior to the insured's coverage under this
policy.
23. Duplicate or temporary denture, crown, or bridge.
24. Labial Veneer restorations.
25. General anesthesia and intravenous sedation
administered exclusively for patient management or
comfort.
26. Charges for nitrous oxide.
27. Services, other than those provided to a newborn
child, with respect to congenital (hereditary) or
developmental malformations or cosmetic reasons,
including but not limited to cleft palate, maxillary or
mandibular (upper or lower) malformations, enamel
hypoplasia (lack of development), fluorosis (a type of
discoloration of the teeth), and anodontia
(congenitally missing teeth).
28. Prescribed drugs, premedication or analgesia.
29. Extra oral grafts (grafting of tissues from outside the
mouth to oral tissues).
30. Charges for oral hygiene, plaque control, or diet
instruction.
31. Charges for orthodontia services.
Cancellation, Non-Renewal, or Change in Rates
FCL may modify the rates at any time after the contract
has been in force for twelve (12) months. We will
provide forty-five (45) days’ advance written notice of
cancellation, non-renewal or change in rates at the
policyholder’s last address shown in our records. If we
fail to provide such notice, the policy will remain in effect
at the existing rates until forty-five (45) days after the
notice was mailed. If termination is due to non-payment
of premium, the policy may be cancelled following ten
(10) days’ written notice.
We will honor all valid claims that arise prior to the
termination date.
16672-0307
Termination by the Policyholder
The policyholder may terminate this policy by giving us
thirty-one (31) days’ advance written notice. The
termination will take effect on the last day of the
insurance month for which the policyholder has
requested termination.
Termination by Florida Combined Life
FCL may terminate the policy:
1. if you fail to pay the premium within the grace
period; or
2. if we cancel all contracts with this same form
number; or
3. if you cease to reside in the state of Florida; or
4. upon the death of the policyholder.
Coverage under the policy will terminate for your
dependent(s):
1. if your policy is terminated for any reason; or
2. when they reach the limiting age as specified in this
policy; or
3. in the case of your spouse, upon divorce or legal
separation.
If the policy terminates due to the death of the
policyholder, an individual dental policy may be issued,
upon written request, to dependents whose coverage
terminates. The written request must be received by
FCL within sixty (60) days of the policyholder’s death.
Policy Renewal
You may elect to renew this policy:
1. by timely payment of premiums; and
2. on each policy anniversary;
if you have not received a notice of cancellation or nonrenewal from FCL prior to your renewal date.
Premium rates applicable to this policy will be the rates
currently in use on each renewal date of the policy. FCL
may cancel your policy with forty-five (45) days’ advance
written notice. However, such action will not be taken
solely due to an insured’s health status.
The information provided above is for Policy form
numbers 50573-1106 and 50577-1106. It is provided as
an aid in deciding whether to enroll in these plans. This
document should in no way be construed as part of the
contract. Possession of this document in no way implies
coverage nor does it guarantee benefits under either
plan.
Mail to:
P.O. Box 37859
Jacksonville, FL 32236
BlueDental Choice PPO Application for Individual Insurance
All Fields Are Required
Applicant First Name
Home Phone No.
3 Social Security No.
4
(
)
8
Home Address
5 Suite/Apt No. 6 Business/Other Phone No. 7 Birth Date: (mm/dd/yyyy)
(
)
(Min. applicant age 18)
City
9 State 10 Zip Code
11 Gender 12 Requested Effective Date (within 90 days)
13
M
F
Coverage Type Requested (check all that apply):
Policyholder < 65
Policyholder Age 65+
Child(ren) 14
Spouse < 65
Spouse Age 65+
Domestic Partner (DP) < 65
Domestic Partner (DP) Age 65+
1
Applicant Last Name
2
16
25 26
Student
FT/PT
Spouse
DP
16
Child or
DP Child
16
Child or
DP Child
16
Child or
DP Child
Do you or any of your dependents have Dental insurance under another plan?
Yes
No
If “YES” complete the following: Person’s Name:
Policy No.:
Insurance Co. Name/Address:
Replacement of Coverage. Is this insurance intended to replace ANY dental insurance currently “in-force”?
Yes
No
If “YES” complete the following:
Insurance Company Name:
Policy No.:
Effective Date:
Termination Date:
(Also, read the Replacement of Insurance notice.)
Have you been insured by a Florida Combined Life group or individual dental insurance policy within the last 90 days? Yes
-
27
Covered by
Medicaid
24
Florida Resident
Birth Date
(mm/dd/yyyy)
22 23
You Support
Financially
21
Lives with You
Marital
Status
20
Disabled
Relation
to You
(DP =
Domestic
Partner)
19
Unmarried
No Children
17
Social Security Number
(Please provide in spaces below.)
18
Married
16
First Name, M.I., Last Name
(Please provide information in the
corresponding numbered spaces
below.)
Gender (M/F)
Plan Selection Choice:
Individual BlueDental Choice Plus
Individual BlueDental Choice Copayment 15
List All Eligible Dependents To Be Covered. Children of a domestic partner may be covered when the domestic partner is also covered.
Attach additional sheet of paper, if necessary. Sign and date it.
18 – 27, Check all that apply.
or
-
Are you also applying for Blue Cross and Blue Shield of Florida health insurance coverage?
Yes
No
28
29
No 30
31
Acceptance of Coverage
I am a Florida resident, and I wish to enroll in the above selected plan. I understand the insurance applied for will not become
effective until FCL has approved my application. I understand that waiting periods may apply for certain services.
I authorize FCL to exchange benefit information with any insurance company; organization; or individual to determine if
coordination of benefits applies for me and my dependents. If an overpayment is made, I authorize FCL to recover the excess
from any person or entity to which payment is made.
I acknowledge that FCL coverage is contingent upon the complete, accurate disclosure of the information requested. I certify that
the statements on this application, including any attachment to it, are true and complete to the best of my knowledge and belief. I
understand and agree that any misstatements may result in denial of benefits and/or termination of coverage.
I understand that this application is hereby made a part of the policy. A photocopy of this application shall be as valid as the original.
Fraud Notice: 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 is guilty of a felony of the third degree.
Applicant Signature (Required): X
32 Date (Required):
I understand that FCL may terminate this insurance at the end of any period for which the premium has been paid.
Applicant Signature (Required): X
34 Date (Required):
33
35
Payment Information on Page Two Must be Completed.
50650-1008R
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Web/Telemktg Rev. 1208
Please Complete this Page, and Sign if applicable.
First Name
36 Last Name
37 Social Security No.
38
Agent Information: ALL INFORMATION MUST BE COMPLETED TO PROCESS APPLICATION
Agent Printed Name: Michael Parker
39 Signature:
40 Date:
Agent Phone Number:
42 Agent Fax Number:
Florida State License Number: A200505
44 BCBSF Agent Code: 8890000
Premium Payment Mode:
Monthly Only payable by Bank Draft
(see rate sheet)
Quarterly*
Semi-Annual*
Annual* *Payable by Bank Draft, Check or Credit Card
Payment Method: (Choose One)
41
43
45
46
1. Bank Draft:
For Monthly, Quarterly, Semi-Annual, and Annual Premium Payment Modes
47
You Must Include A Voided Check With This Application For Bank Draft and Complete the Section Below. We will
Deduct your 1st and future premiums from your account.
Policies effective on the 1st of the month will be drafted on the 28th of the previous month; policies effective on the 15th of the
month will be drafted on the 12th of the month.
I authorize _______________________________________________________ to make a bank draft of $_______________________
(Financial Institution/Bank Name)
From Account No. ______________________________________ Bank Routing No. ______________________________________
and to remit the amounts deducted to FCL, upon instructions from FCL. The amount of deduction indicated above is
approximate and may be corrected as instructed by FCL. This authorization will remain in effect until: (a) I/we cancel it in writing;
(b) the above account is closed; (c) the deduction and remittance arrangements between the above financial institution and FCL
are discontinued; or (d) the insurance policy is cancelled. I understand that this authorization does not waive or change any of
the payment provisions of the policy issued to me by FCL, and if this authorization terminates for any reason, any further
payments required under the policy will be made as provided in the policy. I agree that the above financial institution is acting
gratuitously and for my sole accommodation and not as an agent for FCL.
Accountholder’s Signature (Required): X
Date:
2. Check:
For Quarterly, Semi-Annual, and Annual Premium Payment Modes 48 Premium Payment: 49 Check No.: 50
$
Payable to Florida Combined Life (FCL)
52 Exp. Date: (mm/yy) 53
3. Credit Card:
51 Credit Card No.:
For Quarterly, Semi-Annual, and Annual Premium Payment Modes
MasterCard
Visa
I hereby authorize charging by Credit Card:
Cardholder’s Signature: X
54 Amount Charged:
55 Date:
56
$
Please attach your voided check here.
Did You Remember To:
‰
‰
‰
‰
Answer the question about replacement of insurance (Box 29)
Sign and date the application in both places on page 1 (Boxes 32 - 35)
Calculate your premium carefully, using the rate sheet
For Bank Draft, send a voided check that includes the bank routing & account
numbers, and sign/date authorization (Box 47). We will deduct your 1st and future
premiums from your account.
‰ For Credit Card payment, complete all requested information, and sign/date
authorization (Boxes 51 - 56)
For Internal Use Only
PSR No.
Date Processed
Group & Division No.
Policy Effective Date
If you have any questions about completing this application, please call 888-753-4363.
50650-1008R
Page 2 of 2
Web/Telemktg Rev. 1208