Download Certification of Dental Coverage

Certification of Dental Coverage
Employee Name
State of WI Employee ID
Address
Employed by the State of Wisconsin Division of:
I have the following group dental insurance or had the following group dental insurance immediately
prior to the anticipated effective date of this coverage:
q State of Wisconsin Group Health Insurance
Name of Health Plan:
q Other Insurance:
Type of Coverage:  Health
Name of all other plans
 Dental
Dependents:
My dependent(s) has other coverage through an employer or had the following group insurance
immediately prior to the anticipated effective date of this coverage: O Yes O No
If yes, name of dependent(s)
q State of Wisconsin Group Health Insurance
Name of Health Plan:
q Other Insurance:
Type of Coverage:  Health
Name of all other plans
 Dental
Waiting Periods
Waiting periods will be waived for any member changing coverage from other comparable dental
insurance to Dental Wisconsin. For new Dental Wisconsin enrollees without prior dental coverage,
waiting periods will apply. Dental coverage provided through your health insurance may not qualify.
Creditable Coverage
Members with comparable prior dental coverage will be credited for time served under the prior
carrier, as long as there is no more than a 63 day lapse in coverage. Proof of prior coverage may be
required. If a member has preventive dental services through their medical plan and supplemental
dental through Benefits+, this will be considered comparable coverage.
By submitting this form, you understand and certify that no answer or information in this certification
was provided by an agent or anyone else (except for information provided by other family members)
and that all information provided is true, accurate, and complete to the best of your knowledge.
Please mail this form to:
EPIC Enrollment Department
PO Box 8430 • Madison, WI 53708
Fax to: (800) 236-7610
Email: [email protected]
27833-088-1504