853-American Dental PlanAMERICAN DENTAL PLAN
GROUP ENROLLMENT FORM
COMPANY INFORMATION
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Requested Effecffize Date: / ~ [ I / ~ '~.
Eligible Employees:
Initial Enmllees:
B/LL/NG AND RELATED MA1TERS CONTACT
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-PAYROLL' DEDUCTION CYCLES AND EMPLOYEE ELIGIBILITY
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ADDITIONAL INFORMATION
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09: 58A AME(t,~-CAN DEN'TAL PLAN 352-371-9055
S-henandoah Life Insurance Company
A Mutual Company/Home Office- Roanoke, Virginia
APPLICATION FOR GROUP DENTAL
P.O]
POLICY NO...
POLICYHOLDER
THE POLICYHOLDER HEREBY APPLIES TO SHENANDOAH LIFE INSURANCE COMPANY FOR
THE COVERAGE PROVIDED BY GROUP POLICY NO ..... ~? O ~--~-~ .......
THE TERMS OF SAID POLICY ARE HEREBY APPROVED AND ACCEPTED BY THE POLICYHOLD
A COPY OF THIS APPLICATION IS ATTACHED TO AND MADE PART OF THE POLICY.
DATED AT .
·
ON ~'/[ L( .lV~' _ BY
(LTIC ENSED RESIDENT AGENT) "
GA 4.348-IW89
C'x 4] (TRE POLICYHOLDER)
Shenan_doah LifeInsurance Company
A Mutual Company/Home Office- Roanoke, Virginia
APPLICATION FOR GROUP DENTAL
POLICY NO.
THE POLICYHOLDER HEREBY APPLIES TO SHENANDOAH ~ INSURANCE COMPANY FOR
THE COVERAGE PROVIDED BY GROUP POLICY NO. ~ o ox -[ <1
THE TEKMS OF SArD POLICY ARE HEREBY APPROVED AND ACCEPTED BY THE POLICYHOLD, E
A COPY OF THIS APPLICATION IS ATTACHED TO AND MADE PART OF THE POLICY.
(THE POLICYHOLDER)