Group Enrollment Processing

In order to ensure proper processing of your applications, please read the following instructions carefully.

1) Once you have selected the plan(s) in which you wish to enroll, print and complete thecorresponding application(s).

2) Make sure you have signed and completed the application(s) in their entirety. Check them forany errors or missing information.

3) Review, complete and sign the Automatic Deduction Agreement form.

4) Make a photocopy of your voided check for the account from which you would like the premiumdeduction to take place and include it with your forms. Remember, all bank account deductionswill take place on the 1st business day of each month. If we are unable to draft your account onthis day, you may be subject to fees as outlined in the Automatic Deduction Agreement.

5) Email your application with the Automatic Deduction Agreement and the voided check toinsurance@agentbenefits.net. We MUST have all applications by the posted due date orcoverage cannot become effective!

Please call us with any questions you have during the enrollment process.

Group InsuranceBenefi ts Administrator

P: (888) 564-0300, toll freeF: (856) 396-3193E: insurance@agentbenefits.net

DergalisASSOCIATES

Email all finished paperwork to: insurance@agentbenefits.net

Q: Must I take all of the benefits? A: No, each benefit can be purchased individually.

Q: Will I get another opportunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group

Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results.

Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program?

A: Yes, you will have the oppor tunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office.

Q: Is the Automatic Deduction from my checking account the only way to pay? A: Please contact our office at (888) 564-0300 for more information. Additionally, you can use a savings account

as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number. Please note, we are not set up for individual billing and cannot accept a check as payment.

Q: When and how will I receive confirmation of my coverage? A: You should receive an email from our office within three weeks. Please make sure to check your junk mail

folder if you haven’t received the email.

Q: What if I have an emergency before I receive proof of coverage?A: In the event of an emergency situation, you should contact

Someone will help in the transition period.

Q: Why am I not receiving email communication from the group insurance

A: The domain agentbenefits.net may be filtered out by some e-mail providers as “SPAM”. Please ensure to update your email address and communication preferences.

Frequently Asked Questions

Group Insurance at (888) 564-0300.

department?

The Lincoln National Life Insurance Company 1

The Lincoln DentalConnect® PPO Plan:

Covers many preventive,

basic, and major dental care

services

Also covers orthodontic

treatment for children

Features group rates for Bairdand Warner Sales Associates

Lets you choose any dentist

you wish, though you can

lower your out-of-pocket

costs by selecting a network

provider

Does not make you and your

loved ones wait six months

between routine cleanings

Full-Time Sales Associates of Baird and Warner

Benefits At-A-Glance

In-Network Out-of-Network

Calendar (Annual) Deductible

Individual: $50

Family: $150

Waived for: Preventive

Individual: $50

Family: $150

Waived for: Preventive

Deductibles are combined for basic and major In-Network services. Deductibles are combined for basic and major Out-of-Network services.

Annual Maximum $1,500 $1,500

Annual Maximums are combined for preventive, basic, and major services.

Lifetime Orthodontic Max

$1,500 $1,500

Orthodontic Coverage is available for dependent children.

Waiting Period There are no benefit waiting periods for any service

types

Visit LincolnFinancial.com/FindADentist

You can search by:

●Location

●Dentist name or office name

●Distance you are willing to travel

●Specialty, language and more

Your search will automatically provide up to 100 dentists that most

closely match your criteria. If your search does not locate the dentist you

prefer, you can nominate one—just click the Nominate a Dentist link and

complete the online form.

Dental Insurance

$48.90 $110.18 $116.05 $116.05 $142.43

1/1/2020 - 4/30/2021

Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA

2

Preventive Services In-Network Out-of-Network

Routine oral exams

Bitewing X-rays

Full-mouth or panoramic X-rays

Other dental X-rays (including periapical films)

Routine cleanings

Fluoride treatments

Space maintainers for children

Sealants

Biopsy and examination of oral tissue (including brush biopsy)

Labs & other tests

100%

No Deductible

100%

No Deductible

Basic Services In-Network Out-of-Network

Problem focused exams

Palliative treatment (including emergency relief of dental pain)

Injections of antibiotics and other therapeutic medications

Fillings

Prefabricated stainless steel and resin crowns

Simple extractions

Surgical extractions

Oral surgery

General anesthesia and I.V. sedation

Prosthetic repair and recementation services

Periodontal maintenance procedures

Non-surgical periodontal therapy

80%

After Deductible

80%

After Deductible

Major Services In-Network Out-of-Network

Consultations

Endodontics (including root canal treatment)

Periodontal surgery

Bridges

Full and partial dentures

Denture reline and rebase services

Crowns, inlays, onlays and related services

Build-ups/post & core

TMJ

Implants & implant related services

Occlusal guard

50%

After Deductible

50%

After Deductible

Orthodontics In-Network Out-of-Network

Orthodontic exams

X-rays

Extractions

Study models

Appliances

50% 50%

Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA

3

In-Network/Out-of-Network Dentists In-Network Out-of-Network

To find an in-network dentist near you, visit

www.LincolnFinancial.com/FindADentist.

This plan lets you choose any dentist you wish. However, your

out-of-pocket costs are likely to be lower when you choose an in-

network dentist. For example, if you need a crown…

…you pay a deductible (if applicable), then 50% of the remaining discounted fee for PPO members. This is known as a PPO contracted fee.

… you pay a deductible (if applicable), then % of the usual and customary fee, which is the maximum expense covered by the plan. You are responsible for the difference between the usual and customary fee and the dentist’s billed charge.

This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this

summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made

available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a

difference between this summary and the contract, the contract will govern.

Lincoln DentalConnect® health center Web content is provided by go2dental.com, Santa Clara, CA. Go2dental.com is not a Lincoln Financial Group®

company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

Insurance products (policy series GL11) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business

in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Network access plans for specific states are located

on LincolnFinancial.com under the Forms section. Limitations and exclusions apply.

©2018 Lincoln National Corporation LCN-2012491-013118 R 1.0

Dental Insurance | At-A-Glance DTL-ENRO-BRC001-VA

4

Lincoln DentalConnect® Online Health Center Determine the average cost of a dental

procedure

Have your questions answered by a

licensed dentist

Find a dentist based on your home or

workplace location (or even your primary

language)

Get directions to your dentist’s office

Learn all about dental health for children,

from baby’s first tooth to dental

emergencies

Take an in-depth look at dental health

recommendations for seniors

Evaluate your risk for oral cancer,

periodontal disease, and tooth decay

Check your claim status

Print an ID card

Switch between English and Spanish

versions in just one click

Covered Family Members

When you choose coverage for yourself, you can also provide coverage for:

• Spouse

• Dependent children, up to age 26.

Benefit Exclusions

Like any insurance, this dental insurance plan does have some exclusions.

The plan does not cover services started before coverage begins or

after it ends. Benefits are limited to appropriate and necessary

procedures listed in the policy, along with any procedures required

by state law. Benefits are not payable for duplication of services.

Covered expenses will not exceed the policy’s allowances.

Plan benefits are not payable for a condition that is covered under

Workers’ Compensation or a similar law; that occurs during the

course of employment or military service or involvement in an illegal

occupation, felony, or riot; or that results from a self-inflicted injury.

The plan does not cover an orthodontia treatment plan started

before coverage begins unless the member was receiving

orthodontia benefits from the employer’s previous group dental

policy. In this case, Lincoln Financial will continue orthodontia

benefits until the combined benefit paid by both policies is equal to

this policy’s lifetime orthodontia maximum. Plan benefits are not

payable if the orthodontic appliance was installed after the age of 19.

In certain situations, there may be more than one method of treating

a dental condition. This policy includes an alternative benefits

provision that may reduce benefits to the lowest-cost, generally

effective, and necessary form of treatment.

Certain conditions, such as age and frequency limitations, may

impact your coverage. See the plan policy for details.

This plan includes continuation of coverage for Sales Associates with

dental coverage from a previous employer. The member is required

to complete the Continuity of Coverage form located on

www.lfg.com. The form must be provided to us prior to the effective

date to be eligible for continuation of coverage.

A complete list of benefit exclusions is included in the policy. State variations apply.

DergalisASSOCIA TES

HOME ADDRESS

SS #

EMAIL

FIRST

COMPANY NAME OFFICE LOCATION

DENTAL VISION

A. PLEASE CHECK ALL COVERAGE(S) YOU ARE APPLYING FOR

PHONE

CITY

I represent that all information supplied in the application is true and correct. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime.

STATE

BIRTH DATE

HIRE DATE

GENDER

ZIP

M F

ADMINISTRATIVE USE ONLY

EFFECTIVE DATE

Applying for single coverage for myself Applying for myself and dependents listed below

B. PLEASE INDICATE WHO WILL BE INSURED UNDER THE POLICY (CHECK ONLY ONE)

SPOUSECoverage for:

Dental Vision Both

CHILD 1Coverage for:

Dental Vision Both

CHILD 2Coverage for:

Dental Vision Both

CHILD 3Coverage for:

Dental Vision Both

C. ENROLLMENT INFORMATION (COMPLETE IF INCLUDING COVERAGE FOR DEPENDENTS)

GENDER

GENDER

GENDER

GENDER

FIRST

SS#

SS#

SS#

SS#

BIRTH DATE

BIRTH DATE

BIRTH DATE

BIRTH DATE

SIGNATURE DATE

M F

M F

M F

M F

Dental and Vision Insurance Enrollment Form

OCCUPATION

Page 1 of 3

SIGNATURE REQUIRED

MI

MI LAST NAME

DEPENDENT RELATIONSHIP TO EMPLOYEE

DEPENDENT RELATIONSHIP TO EMPLOYEE

DEPENDENT RELATIONSHIP TO EMPLOYEE

DEPENDENT RELATIONSHIP TO EMPLOYEE

LAST

FIRST MI LAST NAME

FIRST MI LAST NAME

FIRST MI LAST NAME

Realtor

SIGNATUREof account owner*

SIGNATUREof insured

*Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions.

Revised 8/6/2019

DATE

DATE

Automatic Deduction and Notification AgreementPLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING:

I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates, to access my account for the

dental, vision, life, and / or disability insurance premiums. I understand that these deductions will be made periodically and I realize that changes in premiums may result in higher or lower deductions. I further understand that I shall incur additional charges in the event this debit is returned for any reason. In the event that Realty Benefits Servicesthe month, I will be charged $25.00. I understand there is no monthly paper billing from Realty Benefit Services, an affiliate of Dergalis Associates and I cannot pay by check.

SOCIAL SECURITY # EMAIL

HOME PHONE

HOME ADDRESSCITY STATE ZIP

CELL PHONE

REALTY COMPANY OFFICE LOCATION

NotificationsI agree to provide signed written notice at least two weeks in advance in the event I wish to cancel, change or amend my current policies. I further agree to indemnify and hold harmless Realty Benefit Services, an affiliate of Dergalis Associates, for charges assessed on my account from my lending institution due to debits for services rendered. I agree to notify Realty Benefit Services, an affiliate of Dergalis Associates, in writing of any changes to my bank account. This notice will be at least two weeks in advance of any scheduled payment debits. (You can email your notice to Dergalis Associates at to insurance@agentbenefits.net.)

I understand that these services are being provided solely through arrangements with Realty Benefit Services, an affiliate of Dergalis Associatesthat I must notify Dergalis Associates in writing if I no longer work as a licensed Realtor or become a

notify Dergalis Associates within 30 days of my termination, I realize I may continue to get billed for

NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS ASSOCIATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY. I understand that any changes to or termination of my coverage will also affect the coverage I have elected for my dependents.

By signing, I acknowledge that I have read and accept the terms of the above notification agreement.

NAME OF INSURED

WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) YES NO

IF YES, WHO:

Page 2 of 3

SIGNATURE REQUIRED

Co-Signature is required if the insured is not listed on the checking account .

Page 3 of 3

Attach Voided Check

Attach Your Business Card

DergalisASSOCIATES