Claremont Insurance Services

Delta Dental Forms
	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)
	Enrollment List Form For New Delta Dental PPO Groups Only, 1 Page (Rev. 12-08)
	Group Application for Small Business Employer Master Group Application for Delta Dental PPO, DeltaCare and Voluntary plans for groups 5-99. , 2 Pages (Rev. 12/08)
	Group Enrollment Checklist 1 Page (Rev. 1-07)
	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. 2005/R7)
	DeltaCare - Plan 11A Plan Description for DeltaCare USA - 11A, 13 Pages (Rev. 2005/R7)
	DeltaCare Plan 12A Plan Description for DeltaCare USA - 12A, 13 Pages (Rev. 2005/R7)
	DeltaCare Plan 15B Plan Description for DeltaCare USA - 15B, 13 Pages (Rev. 2005/R7)
	DeltaCare USA Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to the DeltaCare USA Limitations and Exclusions section for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered., 8 Pages (Rev. 11/08)
	DeltaCare® USA - Rates & Benefits for All Regions 2 Pages (Rev. 11/09)
	Voluntary PPO - Rates & Benefits for All Regions 2 Pages (Rev. 11/09)

Rates - Without DP Maximum
	CLASSIC PPO Plans – Region 1 (Southern California) For groups with 5-49 eligible employees This region includes zip codes 900-908, 910-928 and 930 The following zip codes are excluded: 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013, 93014, 93067, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 2 (Northern California) For groups with 5-49 eligible employees This region includes zip codes 940-941 and 943-951 The following zip codes are excluded: 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 3 (Central Valley, CA) For groups with 5-49 eligible employees This region includes zip codes 932-933, 935-938, 952-953 and 956-958 The following zip codes are excluded: 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 95646, 95724, 95728, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 4 (All Other Regions, CA) For groups with 5-49 eligible employees This region includes zip codes 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013-93014, 93067, 931, 934, 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 939, 942, 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 950, 954-955, 95646, 95724, 95728, 959-961, 2 Pages (Rev. 11/09)
	Options Plans – Region 1 (Southern California) For groups with 50-99 eligible employees This region includes zip codes 900-908, 910-928 and 930 The following zip codes are excluded: 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013, 93014, 93067, 2 Pages (Rev. 11/09)
	Options Plans – Region 2 (Northern California) For groups with 50-99 eligible employees This region includes zip codes 940-941 and 943-951 The following zip codes are excluded: 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 2 Pages (Rev. 11-09)
	OPTIONS Plans – Region 3 (Central Valley, CA) For groups with 50-99 eligible employees This region includes zip codes 932-933, 935-938, 952-953 and 956-958 The following zip codes are excluded: 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 95646, 95724, 95728, 2 Pages (Rev. 11/09)
	OPTIONS Plans – Region 4 (All Other Regions, CA) For groups with 50-99 eligible employees This region includes zip codes 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013-93014, 93067, 931, 934, 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 939, 942, 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 950, 954-955, 95646, 95724, 95728, 959-961, 2 Pages (Rev. 11/09)

Rates - with DP Maximum Waiver
	CLASSIC PPO Plans – Region 1 (Southern California) For groups with 5-49 eligible employees This region includes zip codes 900-908, 910-928 and 930 The following zip codes are excluded: 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013, 93014, 93067, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 2 (Northern California) For groups with 5-49 eligible employees This region includes zip codes 940-941 and 943-951 The following zip codes are excluded: 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 3 For groups with 5-49 eligible employees This region includes zip codes 932-933, 935-938, 952-953 and 956-958 The following zip codes are excluded: 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 95646, 95724, 95728, 2 Pages (Rev. 11/09)
	CLASSIC PPO Plans – Region 4 (All Other Regions, CA) For groups with 5-49 eligible employees This region includes zip codes 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013-93014, 93067, 931, 934, 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 939, 942, 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 950, 954-955, 95646, 95724, 95728, 959-961, 2 Pages (Rev. 11/09)
	Options Plans – Region 1 (Southern California) For groups with 50-99 eligible employees with Diagnostic & Preventive Maximum Waiver® This region includes zip codes 900-908, 910-928 and 930 The following zip codes are excluded: 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013, 93014, 93067, 2 Pages (Rev. 11/09)
	Options Plans – Region 2 (Northern California) For groups with 50-99 eligible employees with Diagnostic & Preventive Maximum Waiver® This region includes zip codes 940-941 and 943-951 The following zip codes are excluded: 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 2 Pages (Rev. 11/09)
	OPTIONS Plans – Region 3 (Central Valley, CA) For groups with 50-99 eligible employees with Diagnostic & Preventive Maximum Waiver® This region includes zip codes 932-933, 935-938, 952-953 and 956-958 The following zip codes are excluded: 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 95646, 95724, 95728, 2 Pages (Rev. 11/09)
	OPTIONS Plans – Region 4 (All Other Regions, CA) For groups with 50-99 eligible employees with Diagnostic & Preventive Maximum Waiver® This region includes zip codes 92222, 92227, 92231-92233, 92243-92244, 92249-92251, 92257, 92259, 92266, 92273, 92275, 92281, 92283, 92328, 92384, 92389, 93013-93014, 93067, 931, 934, 93512-93515, 93517, 93522, 93526, 93529-93530, 93541-93542, 93545-93546, 93549, 939, 942, 94503, 94508, 94510, 94512, 94515, 94533-94535, 94558-94559, 94562, 94567, 94571, 94573-94574, 94576, 94581, 94585, 94589-94592, 94599, 94922-94923, 94926-94928, 94931, 94951-94955, 94972, 94975, 94999, 950, 954-955, 95646, 95724, 95728, 959-961, 2 Pages (Rev. 11/09)

Benefit Summaries
	Classic − PPO A, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO A, Plan 1000 with Ortho Benefit Highlights for PPO dental plan., 2 Pages (Rev. 11/08)
	Classic − PPO A, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO A, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO A, Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO A, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 1000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO B, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 1000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 1000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 1500 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 1500 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 2000 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	Classic − PPO C, Plan 2000 with Ortho BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO, 2 Pages (Rev. 11/08)
	DeltaCare USA Description of Benefits and Copayments The benefits shown here are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to the DeltaCare USA Limitations and Exclusions section for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered., 8 Pages (Rev. 11/08)

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