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Retiree Dental Plan
The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.
Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.
Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.
If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.
Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com
0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.
BUSINESS REPLY M
AILFIRST-CLASS M
AIL PERMIT NO. 6226 NY NY
POSTAGE WILL BE PAID BY ADDRESSEE
From_______________________
______________________________________________________
NO
POSTAG
EN
ECESSARYIF M
AILEDIN
THE
UNITED
STATES
Retiree D
ental P
lan A
dm
inistrator
17 Cou
rt Street Suite 500
Bu
ffalo NY
14202-9922
GEF02-1aDEC 2
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.
For Changes Requested After Initial Enrollment Period Expires
I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: 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 purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Massachusetts: 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 materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kansas, Oregon, and Vermont: 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 anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who
presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
All other states:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.
Member Signature Print Name Date Signed (Mo./Day/Yr.)
Endorsed by
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llme
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rm:
Dire
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Pen
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(Ple
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I expressly acknowledge and understand that NYSUTM
ember Benefits Trust will determ
ine the exact deduction to be withheld monthly and that any questions
regarding the amount will be directed by m
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ber Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a m
ember of NYSUT, an
employee organization entitled to receive union deduction paym
ents as providers by law.
Signature____________________________________________________________Date____________________________________
I belong to the Teachers' Retirement System ofthe
CITYof New York(TRS) and I hereby
request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT
Member Benefits Trust receiveswritten notice from me to the contrary.
I belong to the New York City Board ofEducation Retirement System (BERS).
I belong to the NYSUTStaff Pension Program.
I belong to the New York STATETeachersÌ
Retirement System (NYSTRS), or
New York ST ATEEmployees' Retirement
System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT
MemberBenefits Trust receives written notice from meto the contrary.
I am a TIAAand/or CREF annuitant and
hereby request a monthly withholding ofdeductions from my monthly TIAA
and/orCREF income for the purchase of coveragesprovided through NYSUT
Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.
Place Union Bug Here
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We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:
Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company
The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:
• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.
• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.
• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.
With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.
If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.
Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.
How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.
2
* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.
** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.
DetA
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15
GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922
(Continued on Following Page)1 NYSUT – Retiree (12/08)
Metropolitan Life Insurance Company, New York, NY
DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER
Name of Association
NYSUT Member Benefits Trust
Group Report No.
105643
Sub Division
N/A
Branch
N/A
Association’s Street Address
800 Troy-Schenectady Road
City
Latham
State
NY
Zip Code
12110-2455
Coverage Effective Date (Mo./Day/Yr.)
Work Status: Retiree
SECTION TO BE COMPLETED BY MEMBER (Please Print)
Name First Middle Last
Social Security No.
Date of Birth (Mo./Day/Yr.)
Male
Female
Address Street City State Zip Code
Marital Single Married
Status: Widowed Divorced
E-mail Address
Phone No. (include area code)
COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)
Retired Member Only
Retired Member + One Dependent
Retired Member + Spouse/Domestic Partner and Child(ren)
If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:
Number of dependents (including spouse/domestic partner)
Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)
Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)
Last
Nam
e___
____
____
____
____
____
____
____
_ F
irst_
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____
____
__ I
nitia
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Add
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NYSU
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If yo
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, pl
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er
your
ret
irem
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____
____
____
____
____
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(Ple
ase
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:
The plan also offers you a choice; you may use a participating PDP dentist (in-network) or you may use an out-of-network dentist. If you choose to receive services from a participating PDP dentist, you will generally receive the greater benefit and incur the least out-of pocket expense.
If you use a participating PDP dentist, the plan provides paid-in-full benefits for Type A services. You will have out-of-pocket costs for Type B and Type C services provided by PDP dentists. Also, when PDP dentists are used, services are not subject to any deductibles.
If you use an out-of-network dentist, you generally will have higher out-of-pocket costs for all types of service. In addition, Type B and Type C services are subject to an annual deductible ($50 for individual coverage, $100 for family coverage).
There is an annual benefit maximum of $1,250 per person under this plan for covered services rendered by PDP and non-participating dentists.
IN-NETWORK BENEFITWhen you or your eligible dependent visit a participating Preferred Dentist Program (PDP) dentist, plan benefits are based on a negotiated fee schedule. You will be responsible for the difference between the negotiated PDP fee for a given service and the percentage of the PDP fee that your plan covers for that service.
Benefit Summary: Plan Coverage: Type A - Preventive 100% of PDP Fee* Type B - Basic Restorative 60% of PDP Fee* Type C - Major Restorative 35% of PDP Fee*
Annual Deductible: Amount: Individual None Family None
Annual Maximum Benefit: $1,250/person
3
* PDP fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, typically 10 percent to 35 percent below community averages.
** The service categories shown above represent the coverage type for the majority of services within that category. Please refer to your benefits certificate for a complete list and description of covered services.
54
Benefit Summary: Plan Coverage: Annual Deductible: Amount: Type A - Preventive 100% of R&C Fee* Individual $50 Type B - Basic Restorative 60% of R&C Fee* Family $100 Type C - Major Restorative 35% of R&C Fee* Deductibles apply only to Type B and C Benefits
Annual Maximum Benefit: $1,250/person
PRIMARY COVERED SERVICES**Coverage Type of Service How OftenA – Preventive Cleanings • Two per calendar year, separated by a six-month period Exams • Two per calendar year, separated by a six-month period Fluoride Treatments • One per calendar year for dependent children up to 19th birthday X-rays • Full mouth X-rays: one per 60 months • Bitewing X-rays: one set per calendar year for adults; two per
calendar year for dependent children up to 19th birthday, separated by a six-month period
B – Basic Restorative Fillings, Amalgam or Resin • When dentally necessary Simple Extractions • When dentally necessary Labs and Other Tests • When dentally necessary Space Maintainers • For dependent children up to 19th birthday Periodontic Maintenance • Total number of periodontal maintenance treatments and
prophylaxis cannot exceed four in a calendar year Crown, Denture, Bridge Repair • When dentally necessary Endodontics • Root canal treatment limited to once per tooth per 24 months
C – Major Restorative Surgical Extractions • When dentally necessary General Anesthesia • When dentally necessary in connection with oral surgery,
extractions or other covered dental services Oral Surgery • When dentally necessary Periodontics • Periodontal scaling and root planing once per quadrant, every
24 months • Periodontal surgery once per quadrant, every 36 months Relines and Rebases • Relines and rebases to dentures, limited to 36 months (covered
only after six months following the initial installation) Crowns/Inlays/Onlays • Crowns/Inlays/Onlays replacement: once every five years Bridges and Dentures • Initial placement to replace one or more natural teeth which are
lost while covered by the plan • Dentures and bridgework replacement: once every 10 years • Replacement of an existing temporary full denture if the
temporary denture cannot be repaired and the permanent denture is installed within 12 months after the temporary denture was installed
* R&C fees are based on the lowest of a dentist’s usual, actual or community average charge as determined by MetLife.
Out-of-Network Benefit, continued
7
IMPORTANT ENROLLMENT PROVISIONS1. Coverage for all retired members and eligible
dependents who enroll in this dental program will become effective on the first of the month following the date your application was received and accepted.
2. You may change coverage only when you have a Qualifying Event, which changes your family status (e.g., marriage, divorce, the birth or adoption of a child, death of a dependent, termination of your spouse’s employment, etc.). You may enroll or change your enrollment option for coverage within 30 days of the above Qualifying Events.
3. If you leave the program, you will not be permitted to re-enroll.
30-DAY FREE LOOKAfter receiving your confirmation of acceptance in the plan, if you are not satisfied with the terms of your new coverage and no claims have been submitted/paid, simply return the confirmation to the Plan Administrator within 30 days of receipt, and any money you have paid or had deducted from your pension benefit will be refunded in full with no questions asked. Any claim submitted (subsequent to or before disenrollment) by a participant who disenrolls will be denied.
COORDINATION OF BENEFITSThe Retiree Dental Plan contains a Coordination of Benefits clause that may reduce the dental expense benefits payable by the amount of benefits received from another group, employer or government-sponsored plan.
CERTIFICATE OF INSURANCEPlease use the Retire Dental Plan link from www.memberbenefits.nysut.org to link to MetLife’s MyBenefits, where you can view a copy of the Retiree Dental Plan Certificate. The Certificate will describe all benefits, conditions, exclusions and limitations. Please read your Certificate carefully.
OUT-OF-NETWORK BENEFITWhen you or your eligible dependent visit a non-participating dentist, plan benefits are based on the Reasonable and Customary (R&C) charges of dentists in your area as determined by MetLife. You will be responsible for the difference between your dentist’s charge for a given service and the percentage of Reasonable and Customary fee that your plan covers, subject to deductible.
ELIGIBILITY REQUIREMENTSYou must be a NYSUT retiree member at the time of your enrollment to be eligible for the Retiree Dental Plan (underwritten by MetLife).
Coverage is also available for your spouse (or certified domestic partner) and your dependent children. Unmarried, dependent children are covered until the end of the month of their 23rd birthday.
If NYSUT member is deceased while having member and spouse coverage, the surviving spouse may continue the coverage if he or she becomes an associate member of NYSUT.
MONTHLY RATESThe following monthly rates are effective through December 31, 2009:
Retired Member Only – $42.59 per month
Retired Member + One – $94.87 per month
Retired Member + Family – $118.17 per month
PAYMENT METHODSelect your payment method by completing the attached “Authorization Agreement for Dental Insurance Payments” form. You can select from:
• Automatic monthly pension deduction (available if you are collecting a monthly pension benefit from NYSTRS, NYSERS, NYCTRS, or if you are receiving income from a monthly lifetime annuity from TIAA-CREF);
• Quarterly direct billing* (4 payments per year);
• Semi-annual direct billing* (2 payments per year);
• Annual direct billing* (1 payment per year).
6
* You will be charged a $4 service fee per billing cycle for direct billing. There are no service fees if you select pension deduction as your payment method.
methods of treatment that meet generally accepted dental standards. MetLife’s dental consultants may review dental services to determine whether the dental service is necessary in terms of generally accepted dental standards for the purpose of determining the extent to which dental expense benefits are payable under the Retiree Dental Plan.
PROGRAM EXCLUSIONS*This plan does not cover the following services, treatments and supplies:
1) Temporomandibular joint disorders (TMJ)
2) Those received before coverage begins
3) Those not performed by a dentist, except cleaning and scaling of teeth and fluoride treatments performed by a licensed dental hygienist who is supervised and billed by a dentist
4) Cosmetic services, surgery or supplies
5) When covered by any workers’ compensation laws, occupational disease laws or employer’s liability laws, or which an employer is required by law to furnish in whole or in part
6) Which are received through a medical department or similar facility maintained by your employer
7) Home health aids used to prevent decay, such as toothpaste and fluoride gels
8) Appliances or treatment for bruxism (grinding teeth), including, but not limited to, occlusal guards and night guards
9) Duplicate appliances or duplicate prosthetic devices
10) Received where no charge would have been made in the absence of dental expense benefits, or which are not required to be paid
11) Materials or services that are experimental under generally accepted dental standards
12) Received as a result of dental disease, defect or injury due to an act of war, or a warlike act in time of peace, which occurs while coverage is in effect
98
ANSWERS TO YOUR QUESTIONSWhat is a participating PDP dentist?A participating PDP dentist is a general dentist or specialist who meets MetLife’s strict credentialing standards and agree to accept negotiated scheduled fees as a payment in full for services rendered. There are more than 117,000 participating PDP dentist locations nationwide, including more than 27,000 specialists.
How do I find a Participating PDP dentist? You can conduct online provider searches (with direction and mapping capabilities) via the link from the Member Benefits’ website www.memberbenefits.nysut.org. You can also call MetLife toll-free 1-888-883-0046 Mon.-Fri., 6 a.m. to 11 p.m. or Sat., 6 a.m. to 4 p.m., ET. Note: be sure to verify that the dentist still participates in the PDP when you make your appointment.
How are claims paid? Filing a claim is simple. Complete the patient portion of your claim form and your dentist should complete the rest. Either you or your dentist can submit the claim to MetLife for processing. You will receive an explanation of benefits statement showing charges and payments. Benefits will be paid to you unless you have assigned payment to your dentist.
How do I file a claim? Claim forms can be downloaded and printed by using the link from the Member Benefits’ website, www.memberbenefits.nysut.org, or you can call MetLife toll-free at 1-888-883-0046.
Submit Claims To: MetLife Dental PO Box 14588 Lexington, KY 40512
COVERED BENEFITS LIMITATIONSThe fact that a dentist recommends a dental service does not mean dental expense benefits will be paid under the Retiree Dental Plan. Dental expense benefits will be based on the most cost-effective materials and
* Please refer to your benefits certificate for a complete list and description of program exclusions and limitations.
Our Privacy NoticeWe know that you buy our products and services because you trust us. This notice explains how we protect your privacy and treat your personal information. It applies to current and former customers. “Personal information” as used here means anything we know about you personally.
Plan Sponsors and Group Insurance Contract Holders This privacy notice is for individuals who apply for or obtain our products and services under an employee benefit plan, or group insurance or annuity contract. In this notice, “you” refers to these individuals.
Protecting Your Information We take important steps to protect your personal information. We treat it as confidential. We tell our employees to take care in handling it. We limit access to those who need it to perform their jobs. Our outside service providers must also protect it, and use it only to meet our business needs. We also take steps to protect our systems from unauthorized access. We comply with all laws that apply to us.
Collecting Your Information We typically collect your name, address, age, and other relevant information. We may also collect information about any business you have with us, our affiliates, or other companies. Our affiliates include life, car, and home insurers. They also include a bank, a legal plans company, and securities broker-dealers. In the future, we may also have affiliates in other businesses.
How We Get Your Information We get your personal information mostly from you. We may also use outside sources to help ensure our records are correct and complete. These sources may include consumer reporting agencies, employers, other financial institutions, adult relatives, and others. These sources may give us reports or share what they know with others. We don’t control the accuracy of information outside sources give us. If you want to make any changes to information we receive from others about you, you must contact those sources.
13) Instruction for oral care such as hygiene or diet
14) Periodontal splinting
15) Benefits otherwise provided under your employer’s plan or any other plan that your employer or an affiliate contributes to or sponsors
16) Implants
17) Charges for broken appointments or for completing dental forms
18) Sterilization supplies
19) Furnished by a family member
20) For Type C Expenses: 1) Replacement of a lost, missing or stolen crown, bridge or denture. 2) Initial installation of a denture or bridgework to replace one or more natural teeth lost before the Dental Expense Benefits started. 3) Replacement of an existing crown, removable denture or fixed bridgework unless it is needed because the existing crown, denture or bridgework can no longer be used and was installed at least 10 years prior (five years for crowns) to its replacement. 4) Replacement of existing immediate temporary full denture by a new permanent full denture unless: (a) the existing denture cannot be made permanent; and (b) the permanent denture is installed within 12 months after the existing denture was installed.
21) Orthodontia
22) Sealants
10 11
Using Your Information We collect your personal information to help us decide if you’re eligible for our products or services. We may also need it to verify identities to help deter fraud, money laundering, or other crimes. How we use this information depends on what products and services you have or want from us. It also depends on what laws apply to those products and services. For example, we may also use your information to:
• administer your products and services• process claims and other transactions• perform business research• confirm or correct your information• market new products to you• help us run our business• comply with applicable laws
Sharing Your Information With Others We may share your personal information with others with your consent, by agreement, or as permitted or required by law. For example, we may share your information with businesses hired to carry out services for us. We may also share it with our affiliated or unaffiliated business partners through joint marketing agreements. In those situations, we share your information to jointly offer you products and services or have others offer you products and services we endorse or sponsor. Before sharing your information with any affiliate or joint marketing partner for their own marketing purposes, however, we will first notify you and give you an opportunity to opt out.
Other reasons we may share your information include:
• doing what a court, law enforcement, or government agency requires us to do (for example, complying with search warrants or subpoenas)
• telling another company what we know about you if we are selling or merging any part of our business
• giving information to a governmental agency so it can decide if you are eligible for public benefits
• giving your information to someone with a legal interest in your assets (for example, a creditor with a lien on your account)
We may ask for medical information. The Authorization that you sign when you request insurance permits these sources to tell us about you. We may also, at our expense:
• Ask for a medical exam• Ask for blood and urine tests• Ask health care providers to give us health data,
including information about alcohol or drug abuse
We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about:
• Reputation• Driving record• Finances• Work and work history• Hobbies and dangerous activities
The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency.
Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information that it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., 50 Braintree Hill, Suite 400, Braintree, MA 02184-8734, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com.
1312
• giving your information to your health care provider• having a peer review organization evaluate your
information, if you have health coverage with us• those listed in our “Using Your Information”
section above HIPAA
We will not share your health information with any other company – even one of our affiliates – for their own marketing purposes. If you have dental, long term care, or medical insurance from us, the Health Insurance Portability and Accountability Act (“HIPAA”) may further limit how we may use and share your information.
Accessing and Correcting Your Information You may ask us for a copy of the personal information we have about you. Generally, we will provide it as long as it is reasonably retrievable and within our control. You must make your request in writing listing the account or policy numbers with the information you want to access. For legal reasons, we may not show you anything we learned as part of a claim or lawsuit, unless required by law.
If you tell us that what we know about you is incorrect, we will review it. If we agree, we will update our records. Otherwise, you may dispute our findings in writing, and we will include your statement whenever we give your disputed information to anyone outside MetLife.
Questions We want you to understand how we protect your privacy. If you have any questions about this notice, please contact us. When you write, include your name, address, and policy or account number.
Send privacy questions to: MetLife Privacy Office, P. O. Box 489, Warwick, RI 02887-9954 [email protected]
14
Mo
iste
n,
fold
an
d s
eal
We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:
Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company
The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:
• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.
• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.
• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.
With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.
If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.
Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.
How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.
2
* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.
** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.
DetA
CH A
nD
MAI
L In
en
veLo
Pe
15
GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922
(Continued on Following Page)1 NYSUT – Retiree (12/08)
Metropolitan Life Insurance Company, New York, NY
DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER
Name of Association
NYSUT Member Benefits Trust
Group Report No.
105643
Sub Division
N/A
Branch
N/A
Association’s Street Address
800 Troy-Schenectady Road
City
Latham
State
NY
Zip Code
12110-2455
Coverage Effective Date (Mo./Day/Yr.)
Work Status: Retiree
SECTION TO BE COMPLETED BY MEMBER (Please Print)
Name First Middle Last
Social Security No.
Date of Birth (Mo./Day/Yr.)
Male
Female
Address Street City State Zip Code
Marital Single Married
Status: Widowed Divorced
E-mail Address
Phone No. (include area code)
COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)
Retired Member Only
Retired Member + One Dependent
Retired Member + Spouse/Domestic Partner and Child(ren)
If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:
Number of dependents (including spouse/domestic partner)
Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)
Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)
Last
Nam
e___
____
____
____
____
____
____
____
_ F
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__ I
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____
____
____
____
____
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(Ple
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Mo
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We may revise this privacy notice. If we make any material changes, we will notify you as required by law. We provide this privacy notice to you on behalf of these MetLife companies:
Metropolitan Life Insurance Company MetLife Insurance Company of Connecticut General American Life Insurance Company SafeGuard Health Plans Inc. SafeGuard Life Insurance Company
The Retiree Dental PlanThe Retiree Dental Plan endorsed by NYSUT Member Benefits Trust*, which features the MetLife Preferred Dentist Program (PDP), offers easy-to-understand dental coverage that allows you to:
• Protect — you and your family by providing affordable dental coverage for most preventive and routine services that help promote long-term oral health.
• Choose — the dentist of your choice at the time of treatment. You do not have to select a primary dentist; there’s no ID card to show or referrals needed for specialty care.
• Save — on out-of-pocket expenses by receiving services from one of more than 117,000 participating PDP dentist locations nationwide that agree to charge fees typically 10 percent to 35 percent lower than the average charges in your area.
With the MetLife PDP, you receive a wide range of benefits that provides choice, savings** and convenience to help you make your dental health a priority.
If you have questions after you have read this benefit overview, please visit the NYSUT Member Benefits Trust website at www.memberbenefits.nysut.org and click on Retiree Dental Plan under the Insurance navigation bar on the left-hand side of the home page. You will find a Retiree Dental Plan link that will give more information including participating dentists. You can also call MetLife toll-free at 1-888-883-0046.
Note: You may already have retiree dental coverage provided to you through your local association. If not, you may wish to consider this plan when choosing your coverage.
How the Retiree Dental Plan Works The Retiree Dental Plan, underwritten by MetLife, pays benefits for three categories of service: Type A - Preventive, Type B - Basic Restorative, and Type C - Major Restorative. (Please reference the section entitled “Primary Covered Services” for examples of these services.
2
* Coverage is provided under a group insurance policy (Policy form G.2130-S) issued by MetLife.
** Savings from enrolling in the Retiree Dental Plan will depend on various factors, including how often participants visit the dentist and the cost of services covered.
DetA
CH A
nD
MAI
L In
en
veLo
Pe
15
GEF02-1 Please Retain A Copy of The Fully-Completed Form For Your Records andADM Return The Original to Retiree Dental Plan Administrator,17 Court Street Suite 500, Buffalo, NY 14202-9922
(Continued on Following Page)1 NYSUT – Retiree (12/08)
Metropolitan Life Insurance Company, New York, NY
DENTAL ENROLLMENT FORM FOR NYSUT RETIRED MEMBER
Name of Association
NYSUT Member Benefits Trust
Group Report No.
105643
Sub Division
N/A
Branch
N/A
Association’s Street Address
800 Troy-Schenectady Road
City
Latham
State
NY
Zip Code
12110-2455
Coverage Effective Date (Mo./Day/Yr.)
Work Status: Retiree
SECTION TO BE COMPLETED BY MEMBER (Please Print)
Name First Middle Last
Social Security No.
Date of Birth (Mo./Day/Yr.)
Male
Female
Address Street City State Zip Code
Marital Single Married
Status: Widowed Divorced
E-mail Address
Phone No. (include area code)
COVERAGE REQUEST DATA:I have received and read a copy of my association’s current announcement of the group plan. I want to be covered under the group plan for thebenefits for which I am or may become eligible, requested below.I request the following coverage:Coverage Options (Note: Only one of the following may be selected)
Retired Member Only
Retired Member + One Dependent
Retired Member + Spouse/Domestic Partner and Child(ren)
If applying for Dependent coverage (Spouse/Domestic Partner and Child), complete section below:
Number of dependents (including spouse/domestic partner)
Name of Spouse/Domestic Partner (Last, First, MI) Date of Birth Sex (M/F)
Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F)
Last
Nam
e___
____
____
____
____
____
____
____
_ F
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____
____
____
__ I
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___
Add
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____
____
____
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____
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____
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____
____
____
____
____
____
____
____
____
____
Soc
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No.
____
____
____
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____
____
____
_ A
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____
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ents
on
the
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. Sig
natu
re a
nd d
ate
are
requ
ired.
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T M
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0 Tr
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, pl
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ensi
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____
____
____
____
____
____
___
(Ple
ase
Pri
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:
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:
Retiree Dental Plan
The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.
Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.
Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.
If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.
Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com
0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.
BUSINESS REPLY M
AILFIRST-CLASS M
AIL PERMIT NO. 6226 NY NY
POSTAGE WILL BE PAID BY ADDRESSEE
From_______________________
______________________________________________________
NO
POSTAG
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AILEDIN
THE
UNITED
STATES
Retiree D
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inistrator
17 Cou
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Bu
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14202-9922
GEF02-1aDEC 2
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.
For Changes Requested After Initial Enrollment Period Expires
I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: 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 purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Massachusetts: 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 materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kansas, Oregon, and Vermont: 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 anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who
presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
All other states:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.
Member Signature Print Name Date Signed (Mo./Day/Yr.)
Endorsed by
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Gro
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I expressly acknowledge and understand that NYSUTM
ember Benefits Trust will determ
ine the exact deduction to be withheld monthly and that any questions
regarding the amount will be directed by m
e to Mem
ber Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a m
ember of NYSUT, an
employee organization entitled to receive union deduction paym
ents as providers by law.
Signature____________________________________________________________Date____________________________________
I belong to the Teachers' Retirement System ofthe
CITYof New York(TRS) and I hereby
request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT
Member Benefits Trust receiveswritten notice from me to the contrary.
I belong to the New York City Board ofEducation Retirement System (BERS).
I belong to the NYSUTStaff Pension Program.
I belong to the New York ST ATETeachersÌ
Retirement System (NYSTRS), or
New York ST ATEEmployees' Retirement
System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT
MemberBenefits Trust receives written notice from meto the contrary.
I am a TIAAand/or CREF annuitant and
hereby request a monthly withholding ofdeductions from my monthly TIAA
and/orCREF income for the purchase of coveragesprovided through NYSUT
Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.
Place Union Bug Here
Reti
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Met
Life
Ret
iree
Den
tal
Plan
is
a N
YSU
T M
emb
er B
enef
its
Tru
st (
Mem
ber
Ben
efit
s)-e
nd
ors
ed p
rog
ram
. M
emb
er
Ben
efit
s h
as a
n e
nd
ors
emen
t ar
ran
gem
ent
of
5% o
f g
ross
p
rem
ium
s fo
r th
is p
rog
ram
. A
ll su
ch p
aym
ents
to
Mem
ber
B
enef
its
are
use
d s
ole
ly t
o d
efra
y th
e co
sts
of
adm
inis
teri
ng
it
s va
rio
us
pro
gra
ms
and
, if
ap
pro
pri
ate,
to
en
han
ce t
hem
. M
emb
er B
enef
its
acts
as
you
r ad
voca
te;
ple
ase
con
tact
M
emb
er B
enef
its
at 8
00-6
26-8
101
if y
ou
exp
erie
nce
a
pro
ble
m w
ith
an
y en
do
rsed
pro
gra
m.
Ag
ency
fee
pay
ers
to N
YSU
T ar
e el
igib
le t
o p
arti
cip
ate
in
NY
SUT
Mem
ber
Ben
efit
s Tr
ust
-en
do
rsed
pro
gra
ms.
Like
mo
st g
rou
p h
ealt
h i
nsu
ran
ce p
olic
ies,
Met
Life
gro
up
p
olic
ies
con
tain
cer
tain
exc
lusi
on
s, l
imit
atio
ns,
wai
tin
g
per
iod
s an
d t
erm
s fo
r ke
epin
g t
hem
in
fo
rce.
Ple
ase
con
tact
M
etLi
fe f
or
com
ple
te d
etai
ls.
If t
her
e is
a c
on
flic
t b
etw
een
th
is b
roch
ure
an
d t
he
gro
up
in
sura
nce
po
licy,
in
clu
din
g t
he
cert
ific
ate,
th
e g
rou
p p
olic
y w
ill g
ove
rn.
Met
rop
olit
an L
ife
Insu
ran
ce C
om
pan
y20
0 Pa
rk A
ven
ue,
New
Yo
rk,
NY
101
66w
ww
.met
life.
com
0909
-275
3
1900
0301
51(0
909)
L020
9021
894(
exp
0210
)(D
C,G
U,M
P,PR
,VI)
© 2
009
MET
LIFE
, IN
C.
BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 6226 NY NY
POSTAGE WILL BE PAID BY ADDRESSEE
From_____________________________________________________________________________
NO POSTAGENECESSARYIF MAILED
IN THEUNITED STATES
Retiree Dental Plan Administrator17 Court Street Suite 500Buffalo NY 14202-9922
GE
F02-1
aD
EC
2
DE
CL
AR
AT
ION
SE
CT
ION
Eac
h pe
rson
sig
ning
bel
ow d
ecla
res
that
all
the
info
rmat
ion
give
n in
thi
s en
rollm
ent
form
is t
rue
and
com
plet
e to
the
bes
t of
his
/her
kno
wle
dge
and
be
lief.
Fo
r C
han
ges
Req
ues
ted
Aft
er In
itia
l En
rollm
ent
Per
iod
Exp
ires
I u
nd
erst
and
tha
t if
dent
al c
over
age
is n
ot e
lect
ed,
a w
aitin
g pe
riod
may
be
requ
ired
befo
re I
can
enr
oll f
or s
uch
cove
rage
afte
r th
e in
itial
enr
ollm
ent
pe
rio
d h
as
exp
ire
d.
Fra
ud
War
nin
g:
If yo
u re
side
in
or a
re a
pply
ing
for
insu
ranc
e un
der
a po
licy
issu
ed i
n on
e of
the
fol
low
ing
stat
es,
plea
se r
ead
the
appl
icab
le w
arni
ng.
New
Yo
rk
[on
ly a
pp
lies
to A
ccid
ent
and
Hea
lth
Ben
efit
s (A
D&
D/D
isab
ility
/Den
tal)
]:
An
y p
erso
n w
ho
kn
ow
ing
ly a
nd
wit
h i
nte
nt
to d
efra
ud
an
y
insu
ran
ce c
om
pan
y o
r o
ther
per
son
file
s an
ap
plic
atio
n f
or
insu
ran
ce c
on
tain
ing
an
y m
ater
ially
fal
se i
nfo
rmat
ion
, o
r co
nce
als
for
the
pu
rpo
seo
f m
isle
adin
g,
info
rmat
ion
co
nce
rnin
g a
ny
fact
mat
eria
l th
eret
o,
com
mit
s a
frau
du
len
t in
sura
nce
act
, w
hic
h i
s a
crim
e, a
nd
sh
all
also
be
sub
ject
to a
civ
il p
enal
ty n
ot
to e
xcee
d f
ive
tho
usa
nd
do
llars
an
d t
he
stat
ed v
alu
e o
f th
e cl
aim
fo
r ea
ch s
uch
vio
lati
on
.
Flo
rid
a: A
ny
per
son
wh
o k
no
win
gly
an
d w
ith
inte
nt
to in
jure
, def
rau
d o
r d
ecei
ve a
ny
insu
rer
file
s a
stat
emen
t o
f cl
aim
or
an a
pp
licat
ion
con
tain
ing
an
y fa
lse,
inco
mp
lete
or
mis
lead
ing
info
rmat
ion
is g
uilt
y o
f a
felo
ny
of
the
thir
d d
egre
e.
Mas
sach
use
tts:
A
ny
per
son
wh
o k
no
win
gly
an
d w
ith
in
ten
t to
def
rau
d a
ny
insu
ran
ce c
om
pan
y o
r o
ther
per
son
file
s an
ap
plic
atio
n f
or
insu
ran
ce c
on
tain
ing
an
y m
ater
ially
fal
se i
nfo
rmat
ion
or
con
ceal
s, f
or
the
pu
rpo
se o
f m
isle
adin
g,
info
rmat
ion
co
nce
rnin
g a
ny
fact
mat
eria
lth
eret
o c
om
mit
s a
frau
du
len
t in
sura
nce
act
, an
d m
ay s
ub
ject
su
ch p
erso
n t
o c
rim
inal
an
d c
ivil
pen
alti
es.
New
Jer
sey:
An
y p
erso
n w
ho
in
clu
des
an
y fa
lse
or
mis
lead
ing
in
form
atio
n o
n a
n a
pp
licat
ion
fo
r an
in
sura
nce
po
licy
is s
ub
ject
to
cri
min
al a
nd
civi
l p
enal
ties
.
Okl
aho
ma:
An
y p
erso
n w
ho
kn
ow
ing
ly,
and
wit
h i
nte
nt
to i
nju
re,
def
rau
d o
r d
ecei
ve a
ny
insu
rer,
mak
es a
ny
clai
m f
or
the
pro
ceed
s o
f an
insu
ran
ce p
olic
y co
nta
inin
g a
ny
fals
e, i
nco
mp
lete
or
mis
lead
ing
in
form
atio
n i
s g
uilt
y o
f a
felo
ny.
Kan
sas,
Ore
go
n, a
nd
Ver
mo
nt:
A
ny
per
son
wh
o k
no
win
gly
an
d w
ith
inte
nt
to d
efra
ud
an
y in
sura
nce
co
mp
any
or
oth
er p
erso
n f
iles
an
app
licat
ion
fo
r in
sura
nce
co
nta
inin
g a
ny
mat
eria
lly f
alse
in
form
atio
n o
r co
nce
als,
fo
r th
e p
urp
ose
of
mis
lead
ing
, in
form
atio
n c
on
cern
ing
an
yfa
ct m
ater
ial
ther
eto
may
be
gu
ilty
of
insu
ran
ce f
rau
d,
and
may
be
sub
ject
to
cri
min
al a
nd
civ
il p
enal
ties
.
Pu
erto
Ric
o:
An
y p
erso
n w
ho
, kn
ow
ing
ly a
nd
wit
h t
he
inte
nt
to d
efra
ud
, pre
sen
ts f
alse
info
rmat
ion
in a
n in
sura
nce
req
ues
t fo
rm, o
r w
ho
pre
sen
ts,
hel
ps
or
has
pre
sen
ted
, a
frau
du
len
t cl
aim
fo
r th
e p
aym
ent
of
a lo
ss o
r o
ther
ben
efit
, o
r p
rese
nts
mo
re t
han
on
e cl
aim
fo
r th
e sa
me
dam
age
or
loss
, will
incu
r a
felo
ny,
an
d u
po
n c
on
vict
ion
will
be
pen
aliz
ed f
or
each
vio
lati
on
wit
h a
fin
e n
o le
ss t
han
fiv
e th
ou
san
d (
5,00
0) d
olla
rsn
or
mo
re t
han
ten
th
ou
san
d (
10,0
00),
or
imp
riso
nm
ent
for
a fi
xed
ter
m o
f th
ree
(3)
year
s, o
r b
oth
pen
alti
es.
If a
gg
rava
ted
cir
cum
stan
ces
pre
vail,
the
fixe
d e
stab
lish
ed i
mp
riso
nm
ent
may
be
incr
ease
d t
o a
max
imu
m o
f fi
ve (
5) y
ears
; if
att
enu
atin
g c
ircu
mst
ance
s p
reva
il, i
t m
ay b
e re
du
ced
to a
min
imu
m o
f tw
o (
2) y
ears
.
Vir
gin
ia a
nd
Was
hin
gto
n:
It is
a c
rim
e to
kn
ow
ing
ly p
rovi
de
fals
e, in
com
ple
te o
r m
isle
adin
g in
form
atio
n t
o a
n in
sura
nce
co
mp
any
for
the
pu
rpo
se o
f d
efra
ud
ing
th
e co
mp
any.
P
enal
ties
in
clu
de
imp
riso
nm
ent,
fin
es a
nd
den
ial
of
insu
ran
ce b
enef
its.
All
oth
er s
tate
s:
An
y p
erso
n w
ho
kn
ow
ing
ly a
nd
wit
h i
nte
nt
to d
efra
ud
an
y in
sura
nce
co
mp
any
or
oth
er p
erso
n f
iles
an a
pp
licat
ion
fo
r in
sura
nce
or
a st
atem
ent
of
clai
m c
on
tain
ing
an
y m
ater
ially
fal
se i
nfo
rmat
ion
or
con
ceal
s, f
or
the
pu
rpo
se o
f m
isle
adin
g,
info
rmat
ion
co
nce
rnin
g a
ny
fact
mat
eria
l th
eret
oco
mm
its
a fr
aud
ule
nt
insu
ran
ce a
ct,
wh
ich
may
be
a cr
ime
and
may
su
bje
ct s
uch
per
son
to
cri
min
al a
nd
civ
il p
enal
ties
.
Sig
nat
ure
(s):
T
he m
embe
r m
ust
sign
in a
ll ca
ses.
T
he p
erso
n si
gnin
g be
low
ack
now
ledg
es t
hat
they
hav
e re
ad a
nd u
nder
stan
d th
e st
atem
ents
and
decl
arat
ions
mad
e in
thi
s en
rollm
ent
form
.
M
embe
r S
igna
ture
Prin
t Nam
eD
ate
Sig
ned
(Mo.
/Day
/Yr.
)
End
orse
d by
Authorization Agreement for Dental Insurance Payments
You have two convenient ways to pay your Dental Insurance Premiums: Pension Deductions from your monthlypension benefit or Direct Billing.
Please check one, complete the information requested below and return this form with your enrollment form:
Direct BillMonthly Pension Deductionfrom pension benefits* Quarterly Direct Bill
Semi-Annual Direct Bill
Annual Direct Bill
* You must complete and sign the two-sided form attached in order to begin Pension deductions.
Do not send any payments now. You will be billed at a later date.
(Please print)
NYSUT Member Name: ____________________________________________________
SS#: _________________________ Phone Number: (____) ______________________
E-mail Address: __________________________________________________________
Street Address: __________________________________________________________
City, State & ZIP: _________________________________________________________
Please mail this completed form to P&A along with your enrollment form to:P&A Group, Attn – Group Insurance Services Department, 17 Court Street, Suite 500, Buffalo, NY 14202
CHECK ONE BOX ONLY - SIGN AND DATE BELOW
I expressly acknowledge and understand that NYSUT Member Benefits Trust will determine the exact deduction to be withheld monthly and that any questionsregarding the amount will be directed by me to Member Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a member of NYSUT, anemployee organization entitled to receive union deduction payments as providers by law.
Signature____________________________________________________________ Date____________________________________
I belong to the Teachers' Retirement System ofthe CITY of New York (TRS) and I herebyrequest a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT Member Benefits Trust receiveswritten notice from me to the contrary.
I belong to the New York City Board ofEducation Retirement System (BERS).
I belong to the NYSUT Staff Pension Program.
I belong to the New York STATE TeachersÌRetirement System (NYSTRS), or
New York STATE Employees' RetirementSystem (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT MemberBenefits Trust receives written notice from meto the contrary.
I am a TIAA and/or CREF annuitant andhereby request a monthly withholding ofdeductions from my monthly TIAA and/orCREF income for the purchase of coveragesprovided through NYSUT Member BenefitsTrustÌ s Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.
Plac
e U
nio
n
Bu
g H
ere
Reti
ree
Den
tal P
lan
Th
e M
etL
ife R
eti
ree D
en
tal
Pla
n i
s a N
YSU
T M
em
ber
Ben
efi
ts
Tru
st (
Mem
ber
Ben
efi
ts)-
en
do
rsed
pro
gra
m.
Mem
ber
Ben
efi
ts h
as
an
en
do
rsem
en
t arr
an
gem
en
t o
f 5%
of
gro
ss
pre
miu
ms
for
this
pro
gra
m.
All
su
ch p
aym
en
ts t
o M
em
ber
Ben
efi
ts a
re u
sed
so
lely
to
defr
ay
the c
ost
s o
f ad
min
iste
rin
g
its
vari
ou
s p
rog
ram
s an
d,
if a
pp
rop
riate
, to
en
han
ce t
hem
. M
em
ber
Ben
efi
ts a
cts
as
you
r ad
voca
te;
ple
ase
co
nta
ct
Mem
ber
Ben
efi
ts a
t 800-6
26-8
101 i
f yo
u e
xperi
en
ce a
p
rob
lem
wit
h a
ny
en
do
rsed
pro
gra
m.
Ag
en
cy f
ee p
aye
rs t
o N
YSU
T a
re e
lig
ible
to
part
icip
ate
in
N
YSU
T M
em
ber
Ben
efi
ts T
rust
-en
do
rsed
pro
gra
ms.
Like m
ost
gro
up
healt
h i
nsu
ran
ce p
oli
cies,
MetL
ife g
rou
p
po
lici
es
con
tain
cert
ain
exc
lusi
on
s, l
imit
ati
on
s, w
ait
ing
p
eri
od
s an
d t
erm
s fo
r keep
ing
th
em
in
fo
rce.
Ple
ase
co
nta
ct
MetL
ife f
or
com
ple
te d
eta
ils.
If t
here
is
a c
on
flic
t b
etw
een
th
is b
roch
ure
an
d t
he g
rou
p
insu
ran
ce p
oli
cy,
incl
ud
ing
th
e c
ert
ific
ate
, th
e g
rou
p p
oli
cy
wil
l g
ove
rn.
Me
tro
po
lita
n L
ife
In
sura
nce
Co
mp
an
y2
00
Pa
rk A
ven
ue
, N
ew
Yo
rk,
NY
10
16
6w
ww
.me
tlif
e.c
om
09
09
-27
53
1
90
00
30
15
1(0
90
9)
L02
09
02
18
94
(exp
02
10
)(D
C,G
U,M
P,P
R,V
I)©
20
09
ME
TLI
FE,
INC
.
BUSINESS REPLY MAILFIRST-CLASS MAIL PERMIT NO. 6226 NY NY
POSTAGE WILL BE PAID BY ADDRESSEE
From_____________________________________________________________________________
NO POSTAGENECESSARYIF MAILED
IN THEUNITED STATES
Retiree Dental Plan Administrator17 Court Street Suite 500Buffalo NY 14202-9922
GE
F02-1
aD
EC
2
DE
CL
AR
AT
ION
SE
CT
ION
Ea
ch p
ers
on
sig
nin
g b
elo
w d
ec
lare
s t
ha
t a
ll th
e i
nfo
rma
tion
giv
en
in
th
is e
nro
llme
nt
form
is
tru
e a
nd
co
mp
lete
to
th
e b
est
of
his
/he
r kn
ow
led
ge
an
db
elie
f.
Fo
r C
han
ge
s R
eq
ue
ste
d A
fte
r In
itia
l E
nro
llm
en
t P
eri
od
Ex
pir
es
I u
nd
ers
tan
d t
ha
t if
de
nta
l co
vera
ge
is
no
t e
lect
ed
, a
wa
itin
g p
eri
od
ma
y b
e r
eq
uir
ed
be
fore
I c
an
en
roll
for
such
co
vera
ge
aft
er
the
in
itia
l e
nro
llme
nt
pe
rio
d h
as
exp
ire
d.
Fra
ud
Wa
rnin
g:
If y
ou
re
sid
e i
n o
r a
re a
pp
lyin
g f
or
insu
ran
ce u
nd
er
a p
olic
y is
sue
d i
n o
ne
of
the
fo
llow
ing
sta
tes,
ple
ase
re
ad
th
e a
pp
lica
ble
wa
rnin
g.
Ne
w Y
ork
[o
nly
ap
pli
es
to
Ac
cid
en
t a
nd
He
alt
h B
en
efi
ts (
AD
&D
/Dis
ab
ilit
y/D
en
tal)
]:
An
y p
ers
on
wh
o k
no
win
gly
an
d w
ith
in
ten
t to
de
fra
ud
an
y
ins
ura
nc
e c
om
pa
ny
or
oth
er
pe
rso
n f
ile
s a
n a
pp
lic
ati
on
fo
r in
su
ran
ce
co
nta
inin
g a
ny
ma
teri
all
y f
als
e i
nfo
rma
tio
n,
or
co
nc
ea
ls f
or
the
pu
rpo
se
of
mis
lea
din
g,
info
rma
tio
n c
on
ce
rnin
g a
ny
fa
ct
ma
teri
al
the
reto
, c
om
mit
s a
fra
ud
ule
nt
ins
ura
nc
e a
ct,
wh
ich
is
a c
rim
e,
an
d s
ha
ll a
lso
be
su
bje
ct
to a
civ
il p
en
alt
y n
ot
to e
xc
ee
d f
ive
th
ou
sa
nd
do
lla
rs a
nd
th
e s
tate
d v
alu
e o
f th
e c
laim
fo
r e
ac
h s
uc
h v
iola
tio
n.
Flo
rid
a:
An
y p
ers
on
wh
o k
no
win
gly
an
d w
ith
in
ten
t to
in
jure
, d
efr
au
d o
r d
ec
eiv
e a
ny
in
su
rer
file
s a
sta
tem
en
t o
f c
laim
or
an
ap
pli
ca
tio
n
co
nta
inin
g a
ny
fa
lse
, in
co
mp
lete
or
mis
lea
din
g i
nfo
rma
tio
n i
s g
uil
ty o
f a
fe
lon
y o
f th
e t
hir
d d
eg
ree
.
Ma
ss
ac
hu
se
tts
: A
ny
pe
rso
n w
ho
kn
ow
ing
ly a
nd
wit
h i
nte
nt
to d
efr
au
d a
ny
in
su
ran
ce
co
mp
an
y o
r o
the
r p
ers
on
fil
es
an
ap
pli
ca
tio
n f
or
ins
ura
nc
e c
on
tain
ing
an
y m
ate
ria
lly
fa
lse
in
form
ati
on
or
co
nc
ea
ls,
for
the
pu
rpo
se
of
mis
lea
din
g,
info
rma
tio
n c
on
ce
rnin
g a
ny
fa
ct
ma
teri
al
the
reto
co
mm
its
a f
rau
du
len
t in
su
ran
ce
ac
t, a
nd
ma
y s
ub
jec
t s
uc
h p
ers
on
to
cri
min
al
an
d c
ivil
pe
na
ltie
s.
Ne
w J
ers
ey
: A
ny
pe
rso
n w
ho
in
clu
de
s a
ny
fa
lse
or
mis
lea
din
g i
nfo
rma
tio
n o
n a
n a
pp
lic
ati
on
fo
r a
n i
ns
ura
nc
e p
oli
cy
is
su
bje
ct
to c
rim
ina
l a
nd
civ
il p
en
alt
ies
.
Ok
lah
om
a:
An
y p
ers
on
wh
o k
no
win
gly
, a
nd
wit
h i
nte
nt
to i
nju
re,
de
fra
ud
or
de
ce
ive
an
y i
ns
ure
r, m
ak
es
an
y c
laim
fo
r th
e p
roc
ee
ds
of
an
ins
ura
nc
e p
oli
cy
co
nta
inin
g a
ny
fa
lse
, in
co
mp
lete
or
mis
lea
din
g i
nfo
rma
tio
n i
s g
uil
ty o
f a
fe
lon
y.
Ka
ns
as
, O
reg
on
, a
nd
Ve
rmo
nt:
A
ny
pe
rso
n w
ho
kn
ow
ing
ly a
nd
wit
h i
nte
nt
to d
efr
au
d a
ny
in
su
ran
ce
co
mp
an
y o
r o
the
r p
ers
on
fil
es
an
ap
pli
ca
tio
n f
or
ins
ura
nc
e c
on
tain
ing
an
y m
ate
ria
lly
fa
lse
in
form
ati
on
or
co
nc
ea
ls,
for
the
pu
rpo
se
of
mis
lea
din
g,
info
rma
tio
n c
on
ce
rnin
g a
ny
fac
t m
ate
ria
l th
ere
to m
ay
be
gu
ilty
of
ins
ura
nc
e f
rau
d,
an
d m
ay
be
su
bje
ct
to c
rim
ina
l a
nd
civ
il p
en
alt
ies
.
Pu
ert
o R
ico
: A
ny p
ers
on
wh
o,
kn
ow
ing
ly a
nd
wit
h t
he i
nte
nt
to d
efr
au
d,
pre
sen
ts f
als
e i
nfo
rmati
on
in
an
in
su
ran
ce r
eq
uest
form
, o
r w
ho
pre
se
nts
, h
elp
s o
r h
as
pre
se
nte
d,
a f
rau
du
len
t c
laim
fo
r th
e p
ay
me
nt
of
a l
os
s o
r o
the
r b
en
efi
t, o
r p
res
en
ts m
ore
th
an
on
e c
laim
fo
r th
e s
am
ed
am
ag
e o
r lo
ss
, w
ill
inc
ur
a f
elo
ny
, a
nd
up
on
co
nv
icti
on
wil
l b
e p
en
ali
zed
fo
r e
ac
h v
iola
tio
n w
ith
a f
ine
no
le
ss
th
an
fiv
e t
ho
us
an
d (
5,0
00
) d
oll
ars
no
r m
ore
th
an
te
n t
ho
us
an
d (
10
,00
0),
or
imp
ris
on
me
nt
for
a f
ixe
d t
erm
of
thre
e (
3)
ye
ars
, o
r b
oth
pe
na
ltie
s.
If a
gg
rav
ate
d c
irc
um
sta
nc
es
pre
va
il,
the
fix
ed
es
tab
lis
he
d i
mp
ris
on
me
nt
ma
y b
e i
nc
rea
se
d t
o a
ma
xim
um
of
fiv
e (
5)
ye
ars
; if
att
en
ua
tin
g c
irc
um
sta
nc
es
pre
va
il,
it m
ay
be
re
du
ce
dto
a m
inim
um
of
two
(2)
years
.
Vir
gin
ia a
nd
Wash
ing
ton
: I
t is
a c
rim
e t
o k
no
win
gly
pro
vid
e f
als
e,
inco
mp
lete
or
mis
lead
ing
in
form
ati
on
to
an
in
su
ran
ce c
om
pan
y f
or
the
pu
rpo
se
of
de
fra
ud
ing
th
e c
om
pa
ny
. P
en
alt
ies
in
clu
de
im
pri
so
nm
en
t, f
ine
s a
nd
de
nia
l o
f in
su
ran
ce
be
ne
fits
.
All
oth
er
sta
tes
:
An
y p
ers
on
wh
o k
no
win
gly
an
d w
ith
in
ten
t to
de
fra
ud
an
y i
ns
ura
nc
e c
om
pa
ny
or
oth
er
pe
rso
n f
ile
s a
n a
pp
lic
ati
on
fo
r in
su
ran
ce
or
a s
tate
me
nt
of
cla
im c
on
tain
ing
an
y m
ate
ria
lly
fa
lse
in
form
ati
on
or
co
nc
ea
ls,
for
the
pu
rpo
se
of
mis
lea
din
g,
info
rma
tio
n c
on
ce
rnin
g a
ny
fa
ct
ma
teri
al
the
reto
co
mm
its
a f
rau
du
len
t in
su
ran
ce
ac
t, w
hic
h m
ay
be
a c
rim
e a
nd
ma
y s
ub
jec
t s
uc
h p
ers
on
to
cri
min
al
an
d c
ivil
pe
na
ltie
s.
Sig
na
ture
(s):
T
he
me
mb
er
mu
st s
ign
in
all
case
s.
Th
e p
ers
on
sig
nin
g b
elo
w a
ckn
ow
led
ge
s th
at
the
y h
ave
re
ad
an
d u
nd
ers
tan
d t
he
sta
tem
en
ts a
nd
de
cla
ratio
ns
ma
de
in
th
is e
nro
llme
nt
form
.
M
em
be
r S
ign
atu
reP
rint N
am
eD
ate
Sig
ne
d (
Mo
./D
ay/
Yr.
)
En
dors
ed b
y
Authorization Agreement for Dental Insurance Payments
You have two convenient ways to pay your Dental Insurance Premiums: Pension Deductions from your monthlypension benefit or Direct Billing.
Please check one, complete the information requested below and return this form with your enrollment form:
Direct BillMonthly Pension Deductionfrom pension benefits* Quarterly Direct Bill
Semi-Annual Direct Bill
Annual Direct Bill
* You must complete and sign the two-sided form attached in order to begin Pension deductions.
Do not send any payments now. You will be billed at a later date.
(Please print)
NYSUT Member Name: ____________________________________________________
SS#: _________________________ Phone Number: (____) ______________________
E-mail Address: __________________________________________________________
Street Address: __________________________________________________________
City, State & ZIP: _________________________________________________________
Please mail this completed form to P&A along with your enrollment form to:P&A Group, Attn – Group Insurance Services Department, 17 Court Street, Suite 500, Buffalo, NY 14202
CHECK ONE BOX ONLY - SIGN AND DATE BELOW
I expressly acknowledge and understand that NYSUT Member Benefits Trust will determine the exact deduction to be withheld monthly and that any questionsregarding the amount will be directed by me to Member Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a member of NYSUT, anemployee organization entitled to receive union deduction payments as providers by law.
Signature____________________________________________________________ Date____________________________________
I belong to the Teachers' Retirement System ofthe CITY of New York (TRS) and I herebyrequest a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT Member Benefits Trust receiveswritten notice from me to the contrary.
I belong to the New York City Board ofEducation Retirement System (BERS).
I belong to the NYSUT Staff Pension Program.
I belong to the New York STATE TeachersÌRetirement System (NYSTRS), or
New York STATE Employees' RetirementSystem (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT MemberBenefits Trust receives written notice from meto the contrary.
I am a TIAA and/or CREF annuitant andhereby request a monthly withholding ofdeductions from my monthly TIAA and/orCREF income for the purchase of coveragesprovided through NYSUT Member BenefitsTrustÌ s Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.
Pla
ce U
nio
n
Bu
g H
ere
Moisten, fold and seal
We m
ay revise this privacy notice. If we m
ake any m
aterial changes, we w
ill notify you as required by law
. We provide this privacy notice to you on behalf of
these MetLife com
panies:
Metropolitan Life Insurance Com
pany M
etLife Insurance Company of Connecticut
General Am
erican Life Insurance Company
SafeGuard Health Plans Inc.
SafeGuard Life Insurance Com
pany
The Retiree Dental Plan
The Retiree D
ental Plan endorsed by NYSU
T Mem
ber Benefits Trust*, w
hich features the MetLife Preferred
Dentist Program
(PDP), offers easy-to-understand
dental coverage that allows you to:
• Protect — you and your fam
ily by providing affordable dental coverage for m
ost preventive and routine services that help prom
ote long-term oral health.
• Choose — the dentist of your choice at the tim
e of treatm
ent. You do not have to select a primary dentist;
there’s no ID card to show
or referrals needed for specialty care.
• Save — on out-of-pocket expenses by receiving
services from one of m
ore than 117,000 participating PD
P dentist locations nationwide that agree to charge
fees typically 10 percent to 35 percent lower than the
average charges in your area.
With the M
etLife PDP, you receive a w
ide range of benefits that provides choice, savings** and convenience to help you m
ake your dental health a priority.
If you have questions after you have read this benefit overview
, please visit the NYSU
T Mem
ber Benefits Trust w
ebsite at ww
w.m
emberbenefits.nysut.org and click
on Retiree Dental Plan under the Insurance navigation
bar on the left-hand side of the home page. You w
ill find a Retiree D
ental Plan link that will give m
ore information
including participating dentists. You can also call MetLife
toll-free at 1-888-883-0046.
Note: You m
ay already have retiree dental coverage provided to you through your local association. If not, you m
ay wish to consider this plan w
hen choosing your coverage.
How
the Retiree Dental Plan W
orks The R
etiree Dental Plan, underw
ritten by MetLife,
pays benefits for three categories of service: Type A -
Preventive, Type B - Basic Restorative, and Type C - Major
Restorative. (Please reference the section entitled “Primary
Covered Services” for examples of these services.
2
* Coverage is provided under a group insurance policy (Policy form G
.2130-S) issued by M
etLife.
** Savings from enrolling in the Retiree Dental Plan w
ill depend on various factors, including how
often participants visit the dentist and the cost of services covered.
DetACH AnD MAIL In enveLoPe
15
GE
F02-1
Ple
ase R
eta
in A
Co
py o
f Th
e F
ully
-Co
mp
lete
d F
orm
Fo
r Yo
ur R
eco
rds a
nd
AD
MR
etu
rn T
he
Orig
ina
l to R
etire
e D
en
tal P
lan
Ad
min
istra
tor,1
7 C
ou
rt Stre
et S
uite
50
0, B
uffa
lo, N
Y 1
42
02
-99
22
(Co
ntin
ue
d o
n F
ollo
win
g P
ag
e)
1N
YS
UT
– R
etire
e (1
2/0
8)
Metro
po
litan L
ife Insu
rance C
om
pan
y, New
Yo
rk, NY
DE
NT
AL
EN
RO
LL
ME
NT
FO
RM
FO
R N
YS
UT
RE
TIR
ED
ME
MB
ER
Nam
e of Association
NY
SU
T M
emb
er Ben
efits Tru
st
Group R
eport No.
10
56
43
Sub D
ivision
N/A
Bra
nch
N/A
Association’s S
treet Address
800 Tro
y-Sch
enectad
y Ro
ad
City
La
tha
m
State
NY
Zip C
ode
12
11
0-2
45
5
Coverage E
ffective Date (M
o./Day/Y
r.)
W
ork Status:
Retiree
SE
CT
ION
TO
BE
CO
MP
LE
TE
D B
Y M
EM
BE
R (P
lease Prin
t)
Nam
eF
irstM
idd
leL
ast
Social S
ecurity No.
Date of B
irth (Mo./D
ay/Yr.)
Male
Fem
ale
Ad
dre
ssS
treetC
ityS
tateZ
ip Code
Marital
Single
Married
Status:
Widow
ed D
ivorced
E-m
ail Address
Phone N
o. (include area code)
CO
VE
RA
GE
RE
QU
ES
T D
AT
A:
I have received and read a copy of my association’s current announcem
ent of the group plan. I want to be covered under the group plan for the
benefits for which I am
or may becom
e eligible, requested below.
I requ
est the fo
llow
ing
coverag
e:C
overag
e Op
tion
s (No
te: Only one of the follow
ing may be selected)
Retired M
ember O
nly
Retired M
ember +
One D
ependent
Retired M
ember +
Spouse/D
omestic P
artner and Child(ren)
If app
lying
for D
epen
den
t coverag
e (Sp
ou
se/Do
mestic P
artner an
d C
hild
), com
plete sectio
n b
elow
:
Num
ber of dependents (including spouse/domestic partner)
Nam
e of Spouse/D
omestic P
artner (Last, First, M
I)D
ate of Birth
Sex (M
/F)
Nam
e(s) of Child(ren) (Last, F
irst, MI)
Date of B
irthS
ex (M/F
)
Last Name________________________________ First_______________ Initial______
Address________________________________________________________________
Home Telephone No. ( )_____________________________________________
Soc. Sec. No._____________________________ Authorization is for_______________(name of plan)
Read statements on the reverse side. Signature and date are required.
NYSUT MEMBER BENEFITS TRUST - 800 Troy-Schenectady Road, Latham, NY 12110-2455
NYSUT MEMBER BENEFITS TRUST PENSION DEDUCTION AUTHORIZATION
If you belong to NYS Employees’
Retirement System, please enter
your retirement/pension number
below. If you are a TIAA-CREF
annuitant, please enter your TIAA
contract number and CREF
certificate number below.
___________________________
(Please Print):
Retirement/Pension Number forNYSERS and TIAA-CREF
Participants:
Retiree Dental Plan
The MetLife Retiree Dental Plan is a NYSUT Member Benefits Trust (Member Benefits)-endorsed program. Member Benefits has an endorsement arrangement of 5% of gross premiums for this program. All such payments to Member Benefits are used solely to defray the costs of administering its various programs and, if appropriate, to enhance them. Member Benefits acts as your advocate; please contact Member Benefits at 800-626-8101 if you experience a problem with any endorsed program.
Agency fee payers to NYSUT are eligible to participate in NYSUT Member Benefits Trust-endorsed programs.
Like most group health insurance policies, MetLife group policies contain certain exclusions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife for complete details.
If there is a conflict between this brochure and the group insurance policy, including the certificate, the group policy will govern.
Metropolitan Life Insurance Company200 Park Avenue, New York, NY 10166www.metlife.com
0909-2753 1900030151(0909)L0209021894(exp0210)(DC,GU,MP,PR,VI)© 2009 METLIFE, INC.
BUSINESS REPLY M
AILFIRST-CLASS M
AIL PERMIT NO. 6226 NY NY
POSTAGE WILL BE PAID BY ADDRESSEE
From_______________________
______________________________________________________
NO
POSTAG
EN
ECESSARYIF M
AILEDIN
THE
UNITED
STATES
Retiree D
ental P
lan A
dm
inistrator
17 Cou
rt Street Suite 500
Bu
ffalo NY
14202-9922
GEF02-1aDEC 2
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form is true and complete to the best of his/her knowledge andbelief.
For Changes Requested After Initial Enrollment Period Expires
I understand that if dental coverage is not elected, a waiting period may be required before I can enroll for such coverage after the initial enrollmentperiod has expired.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: 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 purposeof misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subjectto a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Massachusetts: 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 materialthereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kansas, Oregon, and Vermont: 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 anyfact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who
presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the samedamage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollarsnor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reducedto a minimum of two (2) years.
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
All other states:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material theretocommits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties.
Signature(s): The member must sign in all cases. The person signing below acknowledges that they have read and understand the statements anddeclarations made in this enrollment form.
Member Signature Print Name Date Signed (Mo./Day/Yr.)
Endorsed by
Au
tho
riza
tion
Ag
ree
me
nt fo
r De
nta
l Ins
ura
nc
e P
ay
me
nts
Yo
u h
ave
two
co
nve
nie
nt w
ays to
pa
y y
ou
r De
nta
l Insu
ran
ce
Pre
miu
ms: P
en
sio
n D
ed
uctio
ns fro
m y
ou
r mo
nth
lyp
en
sio
n b
en
efit o
r Dire
ct B
illing
.
Ple
as
e c
he
ck
on
e, c
om
ple
te th
e in
form
atio
n re
qu
es
ted
be
low
an
d re
turn
this
form
with
yo
ur e
nro
llme
nt fo
rm:
Dire
ct B
illM
on
thly
Pen
sio
n D
ed
uctio
nfro
m p
en
sio
n b
en
efits
*Q
ua
rterly
Dire
ct B
ill
Se
mi-A
nn
ua
l Dire
ct B
ill
An
nu
al D
irect B
ill
* You m
ust c
om
ple
te a
nd s
ign th
e tw
o-s
ided fo
rm a
ttached in
ord
er to
begin
Pensio
n d
eductio
ns.
Do
no
t se
nd
an
y p
aym
en
ts n
ow
. Yo
u w
ill be
bille
d a
t a la
ter d
ate
.
(Ple
ase p
rint)
NY
SU
T M
em
be
r Na
me
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SS
#: _
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Ph
on
e N
um
be
r: (__
__
) __
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E-m
ail A
dd
ress: _
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Stre
et A
dd
ress: _
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City
, Sta
te &
ZIP
: __
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Ple
ase m
ail th
is c
om
ple
ted fo
rm to
P&
A a
long w
ith y
our e
nro
llment fo
rm to
:P
&A
Gro
up, A
ttn –
Gro
up In
sura
nce S
erv
ices D
epartm
ent, 1
7 C
ourt S
treet, S
uite
500, B
uffa
lo, N
Y 1
4202
CH
EC
K O
NE
BO
X O
NLY
- SIG
N A
ND
DA
TE
BE
LO
W
I expressly acknowledge and understand that NYSUTM
ember Benefits Trust will determ
ine the exact deduction to be withheld monthly and that any questions
regarding the amount will be directed by m
e to Mem
ber Benefits. I hereby certify to TRS, NYSTRS, NYSERS or TIAA-CREF that I am a m
ember of NYSUT, an
employee organization entitled to receive union deduction paym
ents as providers by law.
Signature____________________________________________________________Date____________________________________
I belong to the Teachers' Retirement System ofthe
CITYof New York(TRS) and I hereby
request a monthly withholding of deductionsfrom my monthly benefit for the purchase ofunion-sponsored benefits as permitted byChapter 248, Laws of 1994. The TRS isauthorized to continue taking such deductionsuntil NYSUT
Member Benefits Trust receiveswritten notice from me to the contrary.
I belong to the New York City Board ofEducation Retirement System (BERS).
I belong to the NYSUTStaff Pension Program.
I belong to the New York STATETeachersÌ
Retirement System (NYSTRS), or
New York ST ATEEmployees' Retirement
System (NYSERS) and I hereby requestmonthly withholding of union deductions frommy monthly benefit as permitted by Section536 of the Education Law and Section 110-Cof the Retirement Social Security Law.NYSTRS or NYSERS is authorized to continuetaking such deduction until NYSUT
MemberBenefits Trust receives written notice from meto the contrary.
I am a TIAAand/or CREF annuitant and
hereby request a monthly withholding ofdeductions from my monthly TIAA
and/orCREF income for the purchase of coveragesprovided through NYSUT
Member BenefitsTrustÌs Pension Advantage program. TIAA-CREF is authorized to continue taking suchdeductions until Member Benefits receiveswritten notice from me to the contrary. If at anytime the total deductions equal or exceed mycombined monthly income payments fromTIAA-CREF, all deductions I have authorizedTIAA-CREF to take on my behalf will terminateimmediately.
Place Union Bug Here