Claremont Insurance Services

Delta Dental Forms
	A Checklist Delta Dental Submission checklist for new groups., 1 Page (Rev. 8-11)
	Application for Small Group Businesses Employer Master Group Application , 2 Pages (Rev. 1/2012)
	Claim Form Dentist's claim form , 1 Page (Rev. 9-08)
	Declination of Dental Coverage For employees who decline dental coverage, 1 Page (Rev. 12/08)
	Enrollment Change Form Employee application and change form for all Delta Dental plans., 1 Page (Rev. 4-09)
	HIPAA Business Associate Agreement Addendum: Group Health Plan (PMI) For DHMO (PMI) groups, 11 Pages (Rev. 4/07)
	HIPAA Business Associate Agreement: Group Health Plan For Delta Premier and Delta Dental PPO groups, , 12 Pages (Rev. 11/03)
	Language Capabilities Disclosure Form Delta Dental of California, 1 Page (Rev. 5-09)
	Language Capabilities Disclosure Form DeltaVision® Program, 1 Page (Rev. 10-08)
	PHI Disclosure Authorization Form Must be signed by employee to authorize release of personal health information to third party. , 1 Page
	Termination of Enrollee Coverage Form 1 Page

DeltaCare USA & Voluntary PPO
	DeltaCare Plan 10A Plan Description for DeltaCare USA - Plan 10A , 13 Pages (Rev. 2011)
	DeltaCare Plan 11A Plan Description for DeltaCare USA - 11A, 13 Pages (Rev. 2011)
	DeltaCare Plan 12A Plan Description for DeltaCare USA - 12A, 13 Pages (Rev. 2011)
	DeltaCare Plan 15B Plan Description for DeltaCare USA - 15B, 13 Pages (Rev. 2011)
	DeltaCare® USA - 2012 Rates 2 Pages (Rev. 2011)
	Voluntary PPO - 2012 Rates 1 Page (Rev. 2011)

Rates - Without DP Maximum
	CLASSIC PPO Plans – Region 1 (Southern California) 2012 For groups with 5-49 eligible employees , 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 2 (Northern California) 2012 For groups with 5-49 eligible employees , 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 3 (Central Valley, CA) 2012 For groups with 5-49 eligible employees , 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 4 (All Other Regions, CA) 2012 For groups with 5-49 eligible employees , 2 Pages (Rev. 2011)
	Options Plans – Region 1 (Southern California) 2012 For groups with 50-99 eligible employees , 2 Pages (Rev. 2011)
	Options Plans – Region 2 (Northern California) 2012 For groups with 50-99 eligible employees , 2 Pages (Rev. 2011)
	OPTIONS Plans – Region 3 (Central Valley, CA) 2012 For groups with 50-99 eligible employees , 2 Pages (Rev. 2011)
	OPTIONS Plans – Region 4 (All Other Regions, CA) 2012 For groups with 50-99 eligible employees , 2 Pages (Rev. 2011)

Rates - with DP Maximum Waiver
	CLASSIC PPO Plans – Region 1 (Southern California) 2012 For groups with 5-49 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 2 (Northern California) 2012 For groups with 5-49 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 3 (Central Valley, CA) 2012 For groups with 5-49 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	CLASSIC PPO Plans – Region 4 (All Other Regions, CA) 2012 For groups with 5-49 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	Options Plans – Region 1 (Southern California) 2012 For groups with 50-99 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	Options Plans – Region 2 (Northern California) 2012 For groups with 50-99 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	OPTIONS Plans – Region 3 (Central Valley, CA) 2012 For groups with 50-99 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)
	OPTIONS Plans – Region 4 (All Other Regions, CA) 2012 For groups with 50-99 eligible employees The D&P Maximum Waiver option allows enrollees to obtain diagnostic and preventive dental services without those costs applying to their plan year maximum benefit amount., 2 Pages (Rev. 2011)

Benefit Summaries
	Classic − PPO A, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO A, Plan 1000 with Ortho Benefit Highlights for PPO dental plan., 2 Pages (Rev. 2011)
	Classic − PPO A, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO A, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO A, Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO A, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B, Plan 1000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO B. Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 1000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)
	Classic − PPO C, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 2011)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com