Administrative Forms

Administrative Guidelines

Do you have questions regarding the rules and regulations of your policy? Our administrative guidelines are a good place to go to get those questions answered.

Employee Enrollment Form

Please use the employee enrollment form to add a new employee to your plan. This form is also used when an employee is adding on a family member or changing their coverage. You can submit a new enrollment via fax or email.
FAX: (310) 391.6534 or Email
customerservice@employeechoicedental.com.

Call Guide for Benefit Administrator

Print this guide and keep it handy in case you need to call us regarding the administration of your plan.

American General Claim Form

The American General Claim Form is required when an employee goes to an out of network dentist. When submitting the claim form, please make sure to send it directly to the American General Processing Center.

Cobra (for 20 or more employees)

Do you have an employee that is leaving the company and wants to keep their coverage? If so, please submit this application to us and we will extend the employee’s coverage per federal guidelines. Please note that the employee will stay on your bill, so you are responsible for billing and collecting premium for that person directly.

Cal Cobra (California Only)

This form is used for employees who wish to continue their group coverage and have either exhausted all applicable COBRA benefits or who work for firms with less than 20 employees. When filling out this form the employee must make sure to sign and date as well as send the first six months payment. Once this form has been processed, a new account is created for the former employee and we bill them directly at their home address. Kelsey National Corporation charges a 10% fee for the administration of CAL-COBRA accounts.

Explanation of Premium

This is a must have for any firm administrator. The Explanation of Premium form is your step-by-step analysis of the information on your bill. It will give you detailed information as to what is on your bill and how to quickly delete former employees from your statement.

Group PPO Dental FAQS

This is a good form to distribute to your employees who have enrolled in any American General plan. It will answer many questions such as how to set an appointment with an in-network dentist and how to navigate American General’s provider directory.

IMPORTANT NOTICE ABOUT NEW ENROLLMENTS

Did you know that an employee application must be submitted within 31 days of the Eligible date to avoid late applicant penalties? The “Important Notice About New Enrollments” gives you helpful suggestions to make sure that all of your enrollment transactions are handled as efficiently as possible.

Renewal Period Guidelines

Your plan has a sixty-day window called the renewal period. During this time, employees are allowed to make certain changes to their account. The “Renewal Period Guidelines” explains what modifications can be made during this valuable time.

PPO Q and A

One of the advantages of a PPO is the flexibility that it offers. The “PPO Q & A” form goes over this in further detail and is an excellent reference guide in case an employee has questions regarding their coverage.

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