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Std 692 form 2026
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- Click ‘Get Form’ to open the std 692 form in the editor.
- Begin with Section A by entering your name and selecting the dental plan you wish to enroll in. If applicable, provide the provider/facility number for prepaid plans.
- In Section B, indicate the type of action: whether you are enrolling for the first time, canceling, or changing plans. Fill out all relevant fields based on your choice.
- If changing family member enrollment, list all current members and specify any additions or deletions along with their action codes in Section B.
- Complete Section C if applicable, providing details about your prior dental plan if you are making changes.
- In Section D, check the appropriate box regarding your enrollment decision and provide your signature and date signed at the bottom of this section.
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std 692 pdf
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I ELECT TO ENROLL IN (OR CHANGE TO) A DENTAL PLAN AS SHOWN ABOVE AND AUTHORIZE DEDUCTIONS TO BE MADE FROM MY SALARY OR RETIREMENT ALLOWANCE TO.Read more
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