dental service center offered by northrop grumman federal … kit 2020-21.pdf · choose a dental...
TRANSCRIPT
DENTAL SERVICE CENTER Dental and Vision Care Plans
DENTAL SERVICE CENTER
To your good health,
Questions? Just call us toll-free at 1-888-293-4903, option 1.
rate sheet for details.
enrollment deadlines for the time you are requesting.NO enrollment during the last quarter. Please see the If you are requesting this kit after our initial open enrollment deadline, there are pro-rated rates and
NO opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year wait for reinstatement.
coverage to begin on July 1, 2020. Please Note: If you cancel during the 1st year of enrollment there is
amount. We must receive your enrollment form(s) and check(s) no later than June 15, 2020 for “Dental Service Center”. You can send your first quarterly payment, or your entire annual premiumboth dental and vision coverage. You must also include separate checks for payment: each made payable to enclosed envelope to return your form(s) to us. You must complete separate enrollment forms to enroll for When you’re ready to enroll, complete the enrollment form(s) for the coverage you want to have and use the
Vision Care Plan options. Be sure to read the enclosed plan materials carefully before making a decision.
Inside this kit, you will find plan details, rates, payment options and enrollment forms for the Dental and
www.vsp.com or call 1-800-877-7195 to locate a provider.
VSP is the largest vision care provider in the United States, with over 71,000 access points. Visit
Vision Service Plan (VSP) Choice Plan:
- 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using our plan ID 3214092.
Advantage Network dentist is easy! Search online at www.cigna.com or call for live customer service addition, they cannot charge you more than their contracted rates for covered services. Finding an bills because CIGNA Advantage Network dentists agree to offer discounts to CIGNA customers. In Choosing a CIGNA Advantage Network dentist (or specialist) will save you money on your dental As a DPPO customer, you may visit any licensed dentist, with no referrals required for specialty care.
Balance freedom and savings with the CIGNA Dental PPO (DPPO)!
our plan ID 3214092.
www.cigna.com or call for live customer service - 24/7 - at 1.800.CIGNA24 (1-800-244-6224) using network coverage with a DHMO plan. Finding a DHMO network dentist is easy! Search online at
payment. No deductibles, no claim forms, no annual maximums! Keep in mind, there is no out-of- primary dentist from the network at enrollment. Specialty care is available with a referral approved for including orthodontic coverage for both children and adults. With the DHMO plan, you choose a Why pay more than you have to for dental care? The CIGNA DHMO plan has comprehensive coverage,
Maximize savings with the CIGNA Dental Care® (DHMO) plan.
Choose a dental care plan from CIGNA and VISION care coverage through VSP!
toll-free1-888-293-4903 option 1.
later than June 15, 2020, your coverage will take effect on July 1, 2020. If you have questions, call us
options below during this annual, limited open enrollment period. When we receive your enrollment no
children can now be on your plan until age 26 with no student verification. Just enroll in any of the
Did you know you can get quality, affordable dental and vision coverage for yourself and your family, and
Welcome to the 2020-2021 Dental and Vision Care plan Enrollment Season!
Phone: 888·293·4903 • Fax: 310·323·7881
Post Office Box 3907 • Gardena, CA 90247-7599
NGFCU membership required to enrollOffered by Northrop Grumman Federal Credit Union
CIGNA Dental Care (HMO) CIGNA Dental PPO
Member Only
Member + One
Member + Family
Important Information about Selecting a CIGNA Dental Plan
Compare Plan features & Monthly Premiums!*
Cigna Dental Care (HMO) New
Patient Charge Schedule P5I0X Minimize out-of-pocket expenses!
CIGNA Dental PPO Visit any licensed dentist!
Finding a Dental Care network dentist is
easy: Call a representative at
1-800-CIGNA24 (1-800-244-6224) or use
the dental office locator at www.cigna.com
No claim forms to file
No deductibles to meet, so your coverage
starts right away.
No Annual dollar maximums, so you don’t
have to postpone any treatment.
Set copays for services
Access to a large credentialed national
network of independent dentists.
Specialty care available, with a referral
approved for payment.
Out-of-network benefits are not available
with the CIGNA Dental Care plan.
Finding an Advantage network dentist is easy: Call a representative at 1-800- CIGNA24 (1-800-244-6224) or use the
dental office locator at www.cigna.com
Save on out of pocket expenses for
treatment when you visit any provider in our
large national PPO Advantage network,
offering the deepest discounts.
Also, save on out of pocket expenses by
visiting a provider in the “Cigna DPPO
network”. These providers offer discounts
(less deep than offered by Advantage
provider), at the out-of-network benefit
level.
In-network or not, you’ll be reimbursed for
all or part of the cost for covered services
up to your annual dollar maximum, after
meeting your deductible.
Out of pocket expenses will be higher when
you visit a non-network dentist.
Most network dentist file claim forms for
members; members must file claims for out-
of-network care.
No referral necessary to see a specialist.
fast, accurate, convenient claims processing.
Monthly Rate*
*Monthly rates are for comparison only. Premiums are paid annually or
quarterly. Please refer to the Rate sheet included.
NG 3/18
$26.74$52.71
$73.63
$48.38$80.91
$120.39
More reasons to SMILE
CIGNA Dental Care (HMO) Sample Patient Charges P5I0X
NG 3/18
This Overview shows you a sampling of covered services and what you will pay with your CIGNA Dental Care Plan compared to what
you would pay without coverage. You will receive a complete NEW Patient Charge Schedule after your enrollment.
Key Highlights of the CIGNA Dental Care Plan
This plan offers coverage for a wide range of services at a cost savings. Coverage includes:
Preventive Care (cleanings, x-rays, and more) No Deductibles
Basic Care (fillings, basic restorative work) No dollar maximums
Major Service (bridges, crowns, root canals and more) No claim forms
No waiting periods Low co-payments
What You’ll Pay
Code Procedure Description
Current
P5I0X
Without Dental
Coverage*
D1110 Prophylaxis Cleaning – Adult (Limit 1 every 6 months) $0 $150
D0150 Comprehensive Oral Evaluation – New or Established Patient $0 $160
D1206 Topical Fluoride Application – Child (Up to 19th Birthday) (once in 6 months) $0 $75
D0210 X-Rays – Complete Series (including bitewings) (Limit 1 every 3 years) $0 $225
D1351 Sealant – Per Tooth $10 $102
D2150 Amalgam – Two Surface, Primary or Permanent $0 $300
D2330 Resin-Based Composite – One Surface, Anterior $0 $300
D2160 Amalgam – Three Surfaces, Primary or Permanent $0 $347
D2391 Resin-Based Composite – One Surface, Posterior $55 $295
D3310 Anterior Root Canal (Permanent Tooth) (Excluding Final Restoration) $80 $1167
D3330 Molar Root Canal (Permanent Tooth) (Excluding Final Restoration) $250 $1600
D8080
D8660
D8670
D8680
D8999
Comprehensive Orthodontic Treatment of the Adolescent Dentition (Banding)
Pre-Orthodontic Treatment Visit
Periodic Orthodontic Treatment Visit - Child (Up to 19th Birthday) (As Part of
Contract)-24 months of active treatment
Orthodontic Retention (Removal of Appliances, Construction and Placement of
Retainer(s))
Unspecified Orthodontic Procedure, By Report (Orthodontic Treatment Plan and
Records)
$400
$125
$1340
$275
$270
(Varies depending
on treatment)
D4341 Periodontal Scaling and Root Planning, Four or More Teeth or bounded Teeth Spacers
per quadrant (Limit 4 Quadrants per Consecutive 12 months)
$40
$350
D4910 Periodontal Maintenance Cleaning (Limit of 2 Within the First 12 Months After Active
Therapy)
$30
$200
Additional Periodontal Maintenance (beyond the 2 per calendar year) $55 $200
D7210 Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth $30 $487
D7140 Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Removal) $5 $300
D7240 Removal of Impacted Tooth – Completely Bony $90 $795
D7241 Removal of Impacted Tooth – Completely Bony, Unusual Complications $110 $950
D5214 Lower Partial Denture –Metal (Including Clasps, Rests and Teeth) $160 $2247
D5110 Full Upper Denture $150 $2170
D5120 Full Lower Denture $150 $2150
D5730 Reline Complete Upper Denture (Chairside) (Limit 1 every 36 months) $35 $2247
D2750 Crown – Porcelain Fused to High Noble Metal $185 $1575
D6750 Crown – Porcelain Fused to High Noble Metal $185 $1500
D6240 Pontic – Porcelain Fused to High Noble Metal $185 $1500
D6010 Surgical placement of implant; Endosteal implant (Limit 1 implant per calendar year) $1025 $3054
D6060 Implant crown-Porcelain fused to Metal $530 $1950
D9220 General Anesthesia – First 30 minutes $160 $505 *Estimated cost without dental coverage are based on Connecticut General Life Insurance Company analysis on average charge for each dental procedure based on geographic
distribution of CIGNA Dental Care membership and national claims analysis, prepared in 2014. Actual charges without dental coverage may differ from your area charges or
local dentist’s fees.
Insured by: Cigna Health and Life Insurance Company
This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents
to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.
Cigna Dental PPO
Network Options In-Network:
Cigna DPPO Advantage Network
Out-of-Network:
Non-Network
Reimbursement Levels Based on Contracted Fees Maximum Allowable Charge
Policy Year Benefits Maximum Applies to: Class I, II, III and IX expenses
$2,000
$1,500
Annual Deductible Individual
Family
$50
$150
$50
$150
Benefit Highlights Plan Pays You Pay Plan Pays You Pay
Class I: Diagnostic & Preventive Oral Exams
Cleanings: prophylaxis
X-rays: bitewing
Fluoride Application
Sealants: per tooth
Space Maintainers: non-orthodontic
100%
No Deductible
No Charge
80%
No Deductible
20%
No Deductible
Class II: Basic Restorative X-rays: full mouth
X-rays: panoramic
X-rays: periapical
Emergency Care to Relieve Pain
Restoration: fillings
Oral Surgery: simple extractions
Cleanings: periodontal maintenance
Periodontics: osseous surgery
Periodontics: periodontal scaling & root planing
Endodontics: root canal therapy
80%
After Annual
Deductible
20%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Class III: Major Restorative Anesthesia: general and IV sedation
Oral Surgery: oral surgical procedures
Oral Surgery: extractions of impacted teeth
Repairs: Bridges, Crowns and Inlays
Repairs: Dentures
Denture Relines, Rebases and Adjustments
Inlays and Onlays
Stainless Steel and Resin Crowns
Crowns, Bridges and Dentures
Prosthesis Over Implant
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Class IX: Implants
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
50%
After Annual
Deductible
Benefit Plan Provisions:
In-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the
dentist according to a Fee Schedule or Discount Schedule.
Non-Network Reimbursement For services provided by non-network dentist, Cigna Dental will reimburse according to the
Maximum Allowable Charge. The dentist may balance bill up to their usual fees.
Cross Accumulation All deductibles, plan maximums, and service specific maximums cross accumulate between in and
out of network. Benefit frequency limitations are based on the date of service and cross accumulate
between in and out of network.
Policy Year Benefits Maximum The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable.
Benefit-specific Maximums may also apply.
Plan Renewal Date:7/1/2020
Dental Service Ctr/Flight Plan Financial
Cigna Dental Benefit Summary
Annual Deductible This is the amount you must pay before the plan begins to pay for covered charges, when applicable.
Benefit-specific deductibles may also apply.
Pretreatment Review Pretreatment review is available on a voluntary basis when dental work in excess of $500 is
proposed.
Alternate Benefit Provision When more than one covered Dental Service could provide suitable treatment based on common
dental standards, Cigna HealthCare will determine the covered Dental Service on which payment
will be based and the expenses that will be included as Covered Expenses.
Oral Health Integration Program (OHIP) Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with
the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer
radiation, organ transplants and chronic kidney disease. There’s no additional charge for the
program, those who qualify get reimbursed 100% of coinsurance for certain related dental
procedures. Eligible customers can also receive guidance on behavioral issues related to oral health
and discounts on prescription and non-prescription dental products. Reimbursements under this
program are not subject to the plan deductible, but will be applied to and are subject to the plan
annual maximum. Discounts on certain prescription and non-prescription dental products are
available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire
discounted charge. For more information including how to enroll in this program and a complete
list of program terms and eligible medical conditions, go to www.mycigna.com or call customer
service 24/7 at 1.800.CIGNA24. Benefit Limitations:
Missing Tooth Limitation Provision For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise
payable until covered for 24 months; thereafter, considered a Class III expense.
Oral Exams 1 per 6 consecutive months
X-rays: bitewing 1 set per 12 consecutive months, limited to 4 films per set
X-rays: full mouth or panoramic 1 per 60 consecutive months
X-rays: periapical 4 per 12 consecutive months if not in conjunction with an operative procedure
X-rays: Intraoral occlusal 2 per 12 consecutive months
Cleaning: routine 1 prophylaxis (Class I) or periodontal maintenance (Class III) per 6 consecutive months
Fluoride Application 1 per 12 consecutive months for children under age 14
Sealants: per tooth 1 treatment per lifetime for children under age 14; payable on unrestored permanent bicuspid or
molar teeth only
Space Maintainers Limited to non-orthodontic treatment for children under age 14
Restoration: fillings 1 per 12 consecutive months; applies to replacement of identical surface fillings only, no
composite, white/tooth colored fillings on bicuspid or molar teeth
Inlays and Crowns
Replacement limited to 1 per 84 consecutive months. Benefits are based on the amount payable for
non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.
Replacement must be indicated by major decay. For people under age 16, benefits for crowns and
inlays are limited to resin or stainless steel.
Stainless Steel and Resin Crowns 1 per 36 consecutive months for children under age 16
Endodontic Treatment Root canal retreatment 1 per 24 consecutive months, based on necessity
Periodontal Scaling and Root Planning 1 per quadrant per 36 consecutive months
Dentures and Partials Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired
Denture Adjustments Covered if more than 12 consecutive months after installation; 1 per 12 consecutive months
Denture Repairs Covered if more than 12 consecutive months after installation
Denture Rebases and Relines Covered if more than 12 consecutive months after installation; 1 per 36 consecutive months
Prosthesis Over Implant
1 per 84 consecutive months if unserviceable and cannot be repaired. Benefits are based on the
amount payable for non-precious metals. No porcelain or white/tooth colored material on molar
crowns or bridges
Bridges
Replacement limited to 1 per 84 consecutive months, if unserviceable and cannot be repaired.
Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth
colored material on molar crowns or bridges
Model Payable only in conjunction with orthodontic workup
Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following:
Procedures and services not listed under Benefit Highlights;
Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet;
Restorative: core buildup; labial veneers; precious or semi-precious metals for crowns, bridges, pontics and abutments; restoration of teeth which have
been damaged by erosion, attrition or abrasion;
Periodontics: bite registrations; splinting; Prosthodontics: overdentures; precision or semi-precision attachments;
Orthodontics: orthodontic treatment, myofunctional therapy;
Anesthesia: IV sedation or general anesthesia, except when medically or dentally necessary and when in conjunction with covered complex oral
surgery; Drugs: prescription drugs;
Procedures, appliances or restorations, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize
periodontally involved teeth, or restore occlusion;
Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization;
Services that are deemed to be medical in nature; Services and supplies received from a hospital;
Charges in excess of the Maximum Allowable Charge.
Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.
This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the
terms of the official plan documents will prevail.
Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance
Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental
plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy”
refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et
al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
BSDXXXXX © 2017 Cigna
Get access to the best in eye care andeyewear with NGC Retirees and VSP®
Vision Care.Why enroll in VSP? As a member, you’ll receive access to carefrom great eye doctors, quality eyewear, and the affordabilityyou deserve, all at low out-of-pocket costs.
You’ll like what you see with VSP.Value and Savings. You’ll enjoy more value and low out-of-pocket costs.
High Quality Vision Care. You’ll get great care from a VSP network doctor,including a WellVision Exam®—a comprehensive exam designed to detecteye and health conditions.
Choice of Providers. The decision is yours to make—with the largestnational network of private-practice doctors, plus participating retailchains, it's easy to find the in-network doctor who's right for you.
Great Eyewear. It’s easy to find the perfect frame at a price that fits yourbudget.
Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective, review yourbenefit information.
Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID cardnecessary. If you’d like a card as a reference, you can print one onvsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete whenyou see a VSP provider.
Choice in EyewearFrom classic styles to the latest designer frames, you’ll find hundreds ofoptions. Choose from featured frame brands like bebe, CALVIN KLEIN,Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more.1 Visit vsp.com tofind a Premier Program location that carries these brands. Plus, save up to40% on popular lens enhancements.2 Prefer to shop online? Check out allof the brands at eyeconic.com®, VSP's preferred online eyewear store.
Enroll in VSP today.You'll be glad you did.Contact us. 800.877.7195vsp.com
Life is better in focus. TM
VSP Provider Network: VSP ChoiceFrequencyCopayDescriptionBenefit
Your Coverage with a VSP Provider
Every 12 months$20WellVision Exam Focuses on your eyes and overall wellness
See frame and lenses$25Prescription Glasses
Every 24 monthsIncluded inPrescription
GlassesFrame
$200 allowance for a wide selection of frames$220 allowance for featured frame brands20% savings on the amount over your allowance$110 Costco® frame allowance
Every 12 monthsIncluded inPrescription
GlassesLenses Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children
Every 12 months
$0
Lens Enhancements
Standard progressive lenses$95 - $105Premium progressive lenses$150 - $175Custom progressive lenses
Average savings of 20-25% on other lens enhancements
Every 12 monthsUp to $60Contacts (instead ofglasses)
$150 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)
As needed$20Diabetic Eyecare PlusProgram
Services related to diabetic eye disease, glaucoma and age-relatedmacular degeneration (AMD). Retinal screening for eligible memberswith diabetes. Limitations and coordination with medical coveragemay apply. Ask your VSP doctor for details.
Glasses and Sunglasses
Extra Savings
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12months of your last WellVision Exam.
Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Coverage with Out-of-Network Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Call Member Services for out-of-network plan details.
Exam .............................................................................. up to $45Frame ............................................................................ up to $70Single Vision Lenses ........................................... up to $30
Lined Bifocal Lenses ........................................... up to $50Lined Trifocal Lenses ......................................... up to $65
Progressive Lenses ............................................. up to $50Contacts .................................................................... up to $105
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between thisinformation and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc.,is the legal name of the corporation through which VSP does business.
Contact us. 800.877.7195 | vsp.com1. Brands/Promotion subject to change.2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSPmembers with applicable plan benefits. Ask your VSP network doctor for details.
©2019 Vision Service Plan. All rights reserved.VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of MarchonEyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
VSP Coverage Effective Date: 07/01/2020
Your VSP Vision Benefits SummaryVSP provides you with an affordable eyecare plan.
DENTAL and VISION CARE PLAN RATES
Child must be under the age of 26 and student verification is no longer required.
Rates are payable annually by full payment or quarterly by automatic checking or savings
account deductions (ACH). Any returned Check or ACH is subject to a $20.00 fee (See
agreement below).
When quarterly automatic deductions are elected, the first quarterly payment for each
coverage plan selected must be made with a separate check (payable to the Dental Service
Center) submitted with each signed enrollment form.
To cancel coverage, written notice must be received by the Dental Service Center
no later than the 5th of the month prior to the month the coverage will terminate.
Please Note: If you cancel during the 1st year of enrollment there is NO
opportunity for reinstatement. If you cancel after the 1st year, there is a 2-year
wait for reinstatement.
CIGNA
Dental
HMO
P5I0X
No dental offices in the following states: AK, DE, HI, ID ,ME, MT, ND,
NH, NM, PR, RI, SD, VT, WV, WY
Payment Options: Quarterly Annual
Member Only
Member + One
Member + Family
CIGNA
Dental
Preferred
Provider
Organization
(PPO)
Advantage Network
Available in all states. NOTE: The $50 deductible and $2,000 in-Advantage
Network or $1,500 out-of-network maximum is based on the plan year.
Payment Options: Quarterly Annual
Member Only
Member + One
Member + Family
VSP Vision
Care Plan
Choice Plan
Available in all states.
Payment Options: Quarterly Annual
Member Only $146.76
Member + One $56.88 $227.52
Member + Family $81.96 $327.84
Authorization Agreement for Quarterly Automatic Checking or savings Account Deductions – By enrolling in any of the
dental or vision care plans above, I indicate the following:
I have a checking account at the financial institution named on the enclosed check and, for all debit entries, shall have
funds sufficient to pay such entries. Electronic debit entries shall be initiated by Dental Service Center to pay dental
and/or vision plan costs and other charges for the coverage plans selected and the entries shall constitute my receipt for
the transaction (s).
No payment to Dental Service Center shall be deemed to have been made unless and until Dental Service Center received
actual credit. I also understand that if corrections of the entry are necessary, it may involve an adjustment to my account.
I understand my direct electronic payment of the premium due will be debited on or about the 5th day of each
month prior to the following calendar quarter for which premium is due. (For example, the April-May-June
quarterly premium will be deducted from my account on the 5th of March.).
Dental Service Center reserves the right to refund or terminate electronic payment services. This agreement is to remain
in effect until Dental Service Center terminates it or receives written notification from the enrollee to terminate
participation in the plan and Dental Service Center has sufficient time to act upon the request.
June 30, 2021
through
full plan year enroll for the
You must
June 15, 2020
check(s) by separate
form(s) and enrollment completed Send your $80.22 $320.88
$158.13 $632.52
$220.89 $883.56
$145.14 $580.56$242.73 $970.92
$361.17 $1,444.68
$36.69
DENTAL PLAN APPLICATION
SELECT THE PLAN THAT’S RIGHT FOR YOU PLEASE PRINT
1. CIGNA DPPO Advantage Network
CIGNA DHMO Please choose a dental office from the website
www.cigna.com or 1-800-244-6224. Dental Office Code No.__________
2. I am enrolling: Myself only Myself + One Myself + Family
LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW
Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________
Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.
Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
3. CHOOSE A PAYMENT OPTION – SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—Enclosed is my check to cover the first quarter’s premium for the option I selected above. I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken the 5th of each month prior to the following calendar quarter for which premiums is due. (For example the October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________ Authorized Signature for Automatic Deductions Date
4. I accept the coverage/insurance benefits provided by this group dental plan and authorize the processing of my enrollment in the dental coverage as indicated on this form. I authorize any participating dental office to release dental records and billing information to CIGNA Dental Health for purposes of plan administration.
5. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month
date. I must wait 2 years before I can re-enroll.
6. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date
DENTAL SERVICE CENTER
P. O. Box 3907, Gardena CA 90247-7599 Telephone (888) 293-4903
1. Original to Dental Service Center 2. Copy for your files
VISION CARE PLAN APPLICATION
SELECT THE COVERAGE TYPE THAT’S RIGHT FOR YOU PLEASE PRINT
1. I am enrolling: Myself only Myself + One Myself + Family
LIST ONLY THE MEMBERS WHO ARE TO BE INSURED BELOW
Name: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________________________________ City State Zip _________________________________________________________________________________________________________________________________________________
Telephone Date of Birth Male Female Spouse: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female If more children, enclose information on a separate sheet of paper. Child must be under the age of 26.
Child: LAST FIRST Middle Initial Social Security No.: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
_________________________________________________________________________________________________________________________________________________ Child: LAST FIRST Middle Initial Social Security No: _________________________________________________________________________________________________________________________________________________
Date of Birth Male Female
2. PAYMENT OPTION - SEPARATE CHECKS REQUIRED FOR EACH ENROLLMENT FORM
Annual Check – Enclosed is my annual payment made payable to: Dental Service Center Quarterly Automatic Deduction—I have enclosed a payment for the first quarter and I authorize Dental Service Center to deduct subsequent quarterly payments from my checking account referenced on the enclosed check. I have read and agree to the Authorization Agreement enclosed in this kit. I understand future deductions will be taken on the 5th of each month prior to the following calendar quarter for which premium is due. (For example October, November, December quarterly premium will be taken on the 5th of September.) ____________________________________________________________________ __________________
Authorized Signature for Automatic Deductions Date
3. I accept the coverage/insurance benefits provided by this group vision plan and authorize the processing of my enrollment in the vision plan. I authorize any participating vision office to release vision records and billing information to VSP for purposes of plan administration. 4. I understand that if I cancel this coverage, I must do so in writing and submit it by the 5th of the month prior to the effective cancellation month date. I must wait 2 years before I can re-enroll. 5. New Enrollees may not cancel during the initial plan year. ____________________________________________________________________ ________________ Authorized Signature Date
DENTAL SERVICE CENTER P. O. Box 3907, Gardena CA 90247-7599
Telephone (888) 293-4903 1. Original to Dental Service Center 2. Copy for your files
Complete application, and securely return with a copy of your and (if applicable) the joint account holder’s unexpired driver’s license or state identification card along with your initial deposit. Members must open a Savings account.
PLEASE INDICATE HOW YOU ARE ELIGIBLE FOR MEMBERSHIP:
Employer_______________________________________________ Site______________________________ Employee No.________________________________ or
Family Member. NGFCU Member Name______________________________________________________ Relationship _________________________________ or
Member of Southern California Historical Aviation Foundation
PRODUCT TYPES:Savings account minimum deposit is $5. ____________________________ AMOUNT ENCLOSEDChecking account minimum deposit is $25 __________________________ AMOUNT ENCLOSED
ADDITIONAL SERVICES: ATM Card VISA Debit Card (Checking account required to have debit card) the max! Online Banking
SELECT YOUR DEBIT CARD
Membership Signature Card/Account Application/Agreement
Box Number 47009 | Gardena, California 90247-6809 | Telephone (800) 633-2848 | www.ngfcu.us
MEMBER
FULL NAME (FIRST, MIDDLE, LAST, SUFFIX) SOCIAL SECURITY/TIN
PHYSICAL ADDRESS CITY ST ZIP
MAILING ADDRESS IF DIFFERENT CITY ST ZIP
PHONE CELL HOME WORK PHONE
MOTHER’S MAIDEN NAME CHOOSE A VERBAL PASSWORD FOR SECURITY AND ACCOUNT VERIFICATION
DRIVER’S LIC. OR ID NUMBER ISSUE DATE EXP DATE STATE
EMPLOYER OCCUPATION
EMAIL BIRTHDATE MM/DD/YYYY GENDER M F DO NOT DISCLOSE
JOINT ACCOUNT HOLDER (1)
FULL NAME (FIRST, MIDDLE, LAST, SUFFIX) SOCIAL SECURITY/TIN
PHYSICAL ADDRESS CITY ST ZIP
MAILING ADDRESS IF DIFFERENT CITY ST ZIP
PHONE CELL HOME WORK PHONE
MOTHER’S MAIDEN NAME CHOOSE A VERBAL PASSWORD FOR SECURITY AND ACCOUNT VERIFICATION
DRIVER’S LIC. OR ID NUMBER ISSUE DATE EXP DATE STATE
EMPLOYER OCCUPATION
EMAIL BIRTHDATE MM/DD/YYYY GENDER M F DO NOT DISCLOSE
Globe B-2 Anniversary Card
Additional and/or contingent beneficiary. Use beneficiary designation form.
The applicant hereby applies for membership in Northrop Grumman Federal Credit Union, to subscribe for at least one share and submit documentation herein. The personal information noted below is being requested and maintained in compliance with the provision of Section 326 of the USA PATRIOT Act of 2001.
TERMS AND CONDITIONS: On establishment of membership, Northrop Grumman Federal Credit Union will provide me with its Truth-in-Savings Disclosure and Agreement for various accounts and services offered by Northrop Grumman Federal Credit Union and agree to be bound by the disclosures and agreements contained therein. Further, I/we agree to be bound by the by-laws, regulations, policies and other practices of the Credit Union now in effect or as amended or later adopted regarding this account. The information stated herein is furnished to induce Northrop Grumman Federal Credit Union to open a Regular Share Account and future share accounts. I/we certify that all the information is true and correct. I/we authorize Northrop Grumman Federal Credit Union to obtain consumer reports on me and furnish information concerning my/our account to credit reporting agencies.
I authorize the Credit Union to share my name, address, e-mail address and phone number with any third party utilized to qualify me for membership.
If not applying at an NGFCU branch, please initial the following:
_____________ I agree to receive the account opening disclosures and documents by email at the email address provided on this application. Initial Here
SIGNATURE AND W-9 TAXPAYER ID CERTIFICATIONCheck appropriate boxes: I am not subject to backup withholding due to failure to report interest or dividend income I am subject to backup withholding I am exempt from FATCA reportingThe Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
X ___________________________________________________________________________ ________________________________ MEMBER SIGNATURE DATE
X ___________________________________________________________________________ ________________________________ JOINT ACCOUNT HOLDER 1 SIGNATURE DATE
X ___________________________________________________________________________ ________________________________ JOINT ACCOUNT HOLDER 2 SIGNATURE DATE
Box Number 47009 | Gardena, California 90247-6809 | Telephone (800) 633-2848 | www.ngfcu.us03/20
BENEFICIARY INFORMATION
BENEFICIARY NAME (FIRST, MIDDLE, LAST, SUFFIX) SOCIAL SECURITY BIRTHDATE
PHYSICAL ADDRESS CITY ST ZIP
BENEFICIARY DESIGNATION % RELATIONSHIP TO BENEFICIARY PHONE
BENEFICIARY NAME (FIRST, MIDDLE, LAST, SUFFIX) SOCIAL SECURITY BIRTH DATE
PHYSICAL ADDRESS CITY ST ZIP
BENEFICIARY DESIGNATION % RELATIONSHIP TO BENEFICIARY PHONE
MEMBER NUMBER: _______________________________________________________________________ ACCOUNTS NUMBER(S): ____________________________________________________________
EMPLOYEE NAME: _______________________________________________________________________ DATE RECEIVED: ___________________________________________________________________
OFFICE USE ONLY
JOINT ACCOUNT HOLDER (2)
FULL NAME (FIRST, MIDDLE, LAST, SUFFIX) SOCIAL SECURITY/TIN
PHYSICAL ADDRESS CITY ST ZIP
MAILING ADDRESS IF DIFFERENT CITY ST ZIP
PHONE CELL HOME WORK PHONE
MOTHER’S MAIDEN NAME CHOOSE A VERBAL PASSWORD FOR SECURITY AND ACCOUNT VERIFICATION
DRIVER’S LIC. OR ID NUMBER ISSUE DATE EXP DATE STATE
EMPLOYER OCCUPATION
EMAIL BIRTHDATE MM/DD/YYYY GENDER M F DO NOT DISCLOSE