Obtain a Dental Enrollment Form

Enrollment Required for Coverage to be Effective

When a National IAM Benefit Trust Fund dental plan is negotiated into a collective bargaining agreement, eligible employees must submit a completed Enrollment Form (PDF) to be covered under the plan.

The Fund requires only one enrollment form for all benefit plans under which you and your eligible dependents may be covered (including medical, dental, vision, short-term disability, and life and accidental death and dismemberment benefits). Please use one form for all plans in which you have the opportunity to enroll.

When filling out the form, be sure to list all eligible dependents you wish to cover and, if your coverage includes life and accidental death and dismemberment benefits, please list your beneficiaries. If any dependent child has a last name that is different from yours, or is not your biological child, you must fill out a separate Eligible Dependent Certification Form (PDF).

Waiving Coverage

If you pay all or part of the cost to be covered under a health plan, the Benefit Trust Fund will allow you to waive that coverage. However, choosing to waive medical coverage does not depend on waiving other coverage. You may waive medical coverage separately and keep your other coverage. You may also keep medical coverage only and waive other coverage, or you may waive all coverage completely. You may not waive any coverage that is fully employer paid.

To waive coverage, you must submit a completed Waiver Form (PDF) to the Fund Office. You should also send a copy of the Waiver Form to your employer to prevent your employer from making any unnecessary payroll deductions.

If you choose to waive coverage, the waiver will apply for the duration of the current collective bargaining agreement. However, if you waive coverage because you have coverage under another plan and you later lose that coverage due to unforeseen circumstances, you may submit a petition for special enrollment. To submit a petition for special enrollment, you must send the Fund Office a letter explaining your circumstances. The written request for special enrollment, along with a completed Enrollment Form, must be submitted to the Fund Office within thirty days of the date you lose coverage under the other plan.

You can mail or fax completed forms to the Fund Office as follows:

After Enrollment Forms are processed for a new group, the Fund Office will send participants a packet that provides information about their coverage.

An Enrollment Form should also be completed whenever you want to update the Fund about personal information changes or have a qualifying event. Examples of personal information changes or qualifying events include your change in address, getting married or divorced, adding or deleting a dependent, or changing your beneficiary information.

Whenever you complete an Enrollment Form, be sure to send a copy of the form to your employer to ensure that the appropriate contributions are made for the coverage you select.