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Enrollment

Agent Responsibility

Provide the following information to ODS at least 15 working days prior to the first of the month the coverage is to be effective.

• Premium: One month premium for coverage.
• Group Application: A completed group medical and/or dental application that is signed by both the group and agent.
• Enrollment/Declination Forms: Submit either a completed enrollment or waiver form for each eligible employee.
• Medical and Dental Enrollment (PDF file)
• Medical Only Enrollment (PDF file)
• Dental Only Enrollment (PDF file)
• Declination of Dental Coverage (PDF file)
• Declination of Medical Coverage (PDF file)

ODS Responsibility

ODS will provide the following information to you:

• Group Application
• Enrollment Packets: (depending upon plan selected, some material may vary)
• Member Guides
• Benefit Summaries
• Enrollment Form
• Prescription Drug Claim Form (medical only)
• Mail Service Prescription Program (medical only)
• EyeMed Vision Discount Program
• Declination of Coverage Forms

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Medical insurance products provided by ODS Health Plan, Inc. Dental insurance products provided by Delta Dental Insurance Company and administered by ODS.