Enrollment Kit - metlife (dental)
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Effective Date
Current As Of
"Current As Of" signifies the latest date on which a Word & Brown
Team Member confirmed that the Forms/Document available for download represents the most up-to-date and recently
revised version accessible.
This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines MetLife's case submission requests.
- Specialty Market New Group Submission Form*
- Application for Group Insurance* – (PPO Dental, Life and Disability, Vision)
- DHMO Group Application (if applicable)
- E-Census or Employee Enrollment Forms*
- Copy of Signed Proposal* - Please include entire proposal (rates and benefits)
- Non Standard Commission Agreement (if applicable)
- AXA Travel Assistance Agreement (if AXA is included on Basic or Supplemental Life)
- HIPAA Request Document
- Broker Compensation and Customer Privacy Notices
- Statement of Responsibility (Required for groups with 100+ eligible lives)
- Binder Check (Not required for TPA submissions, add-coverages, or contributory coverages where employees’ contribution is 51% or more)
* indicates the document is required with all submissions
DEADLINES
PPO Dental, Life, Vision, Disability – Please submit all completed forms no later than the 5th business day following the requested effective date. Cases submitted after the 5th business day will go through a late submission review for an exception.
DHMO – Please submit all completed forms no later than the 10th (off peak season) and the 5th (peak season) of the month prior to the
effective date. No exceptions. Employees must be added to the provider’s dental roster prior to the effective date of coverage.
Steps for Submitting Business:
1. Complete the required forms mentioned above
2. Scan and email all completed forms to imp_ratecard@metlifeservice.com
- Specialty Market Submission Form – May be completed by the TPA, GA, Broker or Customer. Customer signature is required. MetLife prefers the form typed, not handwritten.
- Application for Group Insurance – Customer signature is required. The Application for Group Insurance is state specific.
- DHMO Group Application – DHMO is available in TX, CA, NY, NJ and FL. Customer signature is required. The DHMO Group Application is state specific applications. If DHMO sells with Dental PPO and or another line of coverage, please submit the DHMO group application and the Application for Group Insurance for the other lines of coverages sold.
- E-Census or Employee Enrollment Forms – A census is preferred for groups 10+ lives
- Copy of Signed Proposal: Please include the entire proposal (rate and benefits). The proposal may be signed by the TPA, GA, Broker or Customer
- Non Standard Commission Agreement (NSCA) – Required for all groups sold with a non-standard commission scale. Broker signature is required.
- AXA Travel Assistance Agreement – Please submit this form if Supplemental Life is sold. Customer signature is required
- HIPAA Request Document – If the group wants HIPAA, please complete this form.
- Broker Compensation and Customer Privacy Notices – Includes the Customer Privacy Notice and the Intermediary Compensation Notice. For the Broker and Customer to review. Please do not return to MetLife. This packet is located on the Microsite under the “Additional Resources” section.
- Statement of Responsibility Form – Required for groups with 100+ eligible lives or more. Customer signature required.
- Binder Check – Not required for TPA submissions, add-coverages, or contributory coverages where the employees’ contribution is 51% or more. The check should be in the amount of the group’s estimated premium for the first month.
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful or older documents, please refer to the Forms database.