Employee Application Small Group-DHMO - Rogers Benefit Group 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the proposed effective date at the top of the form. This is crucial for processing your application.
3. Fill in your employer or group name and city, ensuring all details are accurate to avoid delays.
4. Indicate the qualifying event by checking the appropriate box, such as 'New business enrollment' or 'Change in family status'.
5. Complete the enrollment information section with personal details including last name, first name, social security number, and date of birth for each individual applying.
6. For prior coverage, answer whether you had dental coverage in the past 12 months and provide details if applicable.
7. Select your desired coverage options by checking the relevant boxes for yourself and any dependents.
8. Finally, review all entered information for accuracy before signing and dating the form at the bottom.

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