Gp54718 03 form 2025

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39 votes

The document is an employee enrollment form for dental insurance provided by Principal Life Insurance Company. It collects personal and employment information from the employee, details about eligible dependents, and includes sections for electing or declining coverage. The form also outlines important agreements regarding coverage eligibility, contributions, and fraud prevention. Employees must sign the form to confirm the accuracy of the information provided.

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Click ‘Get Form’ to open the gp54718 03 form in the editor.
Begin by filling out your personal information in the 'Employee Information' section. Include your name, social security number, mailing address, birth date, and employment details.
Indicate your job occupation and salary information. Select the appropriate options for salary mode and payroll frequency.
In the 'Dental' section, choose whether to elect or decline coverage for yourself, spouse/domestic partner, and children.
If applicable, provide details about any eligible dependents by completing their names and birth dates in the 'Eligible Dependent Information' section.
Read through the Employee Agreement carefully. Once you understand all statements, sign and date the form at the bottom.
After completing the form, make two copies as instructed and send the original to Principal Life Insurance Company.

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