Instructions for Completion of the Dental Plan Enrollment Authorization (STD. 692) 
SECTION A

Active Employees
1.	Type of Action:
•	New: Check if employee is enrolling for the first time, re-enrolling or reinstating from retirement.
•	Cancel: Check if employee is canceling all coverage.
•	Change: Check if employee is currently enrolled and is changing dental plans (only when authorized), adding or deleting family members.
•	COBRA: N/A.

2.	Name and Address:
•	Enter employee’s name and address as shown on EAR document.
3.	PI Employee:
•	Check if employee's time base is Permanent-Intermittent (PI).
4.	Marital Status:
•	Married: Check if employee is married.
•	Single: Check if employee is not married or divorced.
•	Domestic Partner: Check this box.
5.	Sex:
•	Check appropriate box.
6.	Social Security Number:
•	Enter employee’s social security number.

7.	Spouse’s or Domestic Partner’s Social Security Number:
•	Enter spouse or domestic partner’s social security number if applicable.

Retiring Employees
1.	Type of Action:
•	New: Check if employee is continuing coverage into retirement.
•	Cancel: Check if employee elects to cancel current dental plan.
•	Change: Check only if employee is continuing coverage into retirement and current plan is not available in service area.
•	COBRA: N/A.

8.	Name and Address:
•	Enter employee's name and mailing address as reported on CalPERS records.

9.	PI Employee:
•	N/A.

10.	Marital Status:
•	Married: Check if employee is married.
•	Single: Check if employee is not married or divorced.
•	Domestic Partner: Check if employee has a domestic partner.
11.	Sex:
•	Check appropriate box.

12.	Social Security Number:
•	Enter employee’s social security number.

13.	Spouse’s or Domestic Partner’s Social Security Number:
•	Enter spouse or domestic partner’s social security number if applicable.
COBRA Continuation

14.	Type of Action:
•	New: N/A
•	Change: N/A
•	Cancel: N/A
•	COBRA: Check this box

15.	Name and Address:
•	Enter eligible person’s name and address.

16.	PI Employee:
•	N/A

17.	Marital Status:
•	Married: Check if employee is married.
•	Single: Check if eligible person is a dependent continuing coverage.
•	Domestic Partner: Check if employee has a domestic partner.

18.	Sex:
Check appropriate box.

19.	Social Security Number:
•	Enter social security number of eligible person enrolling (i.e. employee, dependent, spouse).

20.	Spouse’s or Domestic Partner’s Social Security Number:
•	Enter spouse or domestic partner’s social security number if spouse is enrolled as a dependent of employee.

SECTION B
Active Employees
1.	Name of Dental Plan: Enter name of dental plan employee is enrolling in.

2.	Provider Facility Number (if applicable): Enter facility number if enrolling in a prepaid plan (i.e. DeltaCare USA, Premier Access, Safeguard, Western).

3.	Enrollment Information:
•	Action Code: Enter "A" for new enrollments or when adding an eligible dependent. Enter "D" if dependent is being deleted.
•	Name/DOB/Relationship: Enter full name, date of birth and relationship of eligible dependent to employee.
•	Gender: Enter appropriate initial (i.e. M or F)

Retiring Employees
1.	Name of Dental Plan: Enter name of dental plan employee is currently enrolled in.

2.	Provider Facility Number (if applicable): Enter facility number if enrolled in a prepaid plan (i.e. DeltaCare USA, Premier Access, Safeguard, Western.)

3.	Enrollment Information:
•	Action Code: Enter "A" for employee and each eligible dependent.
•	Name/DOB/Relationship: Enter full name, date of birth and relationship of eligible dependent to employee.
•	Gender: Enter appropriate initial (i.e. M or F)
COBRA Continuation
1.	Name of Dental Plan: Enter name of dental plan eligible person is currently enrolled in.

2.	Provider Facility Number (if applicable): Enter facility number if enrolled in a prepaid plan (i.e. DeltaCare USA, Premier Access, Safeguard, Western).

3.	Enrollment Information:
•	Action Code: Enter "A" for enrollee and each eligible dependent.
•	Name/DOB/Relationship: Enter full name, date of birth and relationship of eligible dependent to enrollee.
•	Gender: Enter appropriate initial (i.e. M or F)

SECTION C

Active Employees

1.	Prior Dental Plan: Enter name of dental plan being cancelled or changed.

Retiring Employees
•	Enter name of dental plan employee is currently enrolled in, if employee elects to cancel dental coverage prior to retirement or where a change of plan is appropriate.

COBRA Continuation

•	N/A

SECTION D
Active Employees

1.	Election Boxes:
•	First Box: Check if eligible employee does not want dental coverage. Do not send form to SCO or CalHR.
•	Second Box: Check for new enrollment or change to current dental coverage.
•	Third Box: Check for an employee electing to cancel coverage or if a department is cancelling coverage as an "administrative deletion".

2.	Signature: Employee must sign name.
3.	Date Signed: Administrative deletions or cancellations do not require employee signature.

Retiring Employees
1.	Election Boxes:
•	First Box: N/A
•	Second Box: Check if employee is continuing coverage into retirement.
•	Third Box: Check if employee elects to cancel dental coverage.

2.	Signature: Employee signature or Agency may type in "Administrative Document."

COBRA Continuation
1.	Election Boxes:
•	First Box: N/A
•	Second Box: Check if employee or eligible dependents are continuing coverage under COBRA.
•	Third Box: N/A

2.	Signature: Person enrolling must sign name.

SECTION E
Active Employees
1.	Employer Ded. Code:

•	CSU-150: For use by CSU only.
•	Non-CSU-351: Check for all transactions, except cancellations.

2.	Dental Org. Code: Enter three digit dental plan code that corresponds with the employee's choice of dental plan.
3.	Party Code: Enter “1” for employee only; “2” for employee and one dependent; “3” for employee and two or more dependents.
4.	Pay Period*: Enter the month and year (Example: month =01; year =2)
5.	State Share Amount: Enter the amount of the State's contribution.
6.	Employee or CoBEN deduction amount: Enter amount of employee’s share of the premium to be deducted from employee’s pay warrant. If amount is zero (i.e., for prepaid plans), leave blank.
7.	Employee Designation: Enter the employee's CBID as follows: E-Excluded; M-Management; S-Supervisory; C-Confidential; R-Represented.
8.	Bargaining Unit: Enter two digit number that corresponds to the CBID on the PAR document (Example: CBID is R04 - enter 04).
9.	Total Premium Amount: Enter total amount of premium (Amounts from Items E5 + E6 = E9).
10.	Prior Employer Deduction Code: Complete on changes only.

•	CSU-150
•	Non-CSU-351

11.	Prior Dental Org. Code & Party Code: Enter the three digit dental plan code and party code.
12.	Permitting Event Date: Enter the date of the event permitting the action.
13.	Permitting Event Code: Enter appropriate permitting event code.
14.	Effective Date of Action: Enter the appropriate effective date based on the action.
15.	Agency Code: Enter the employee’s agency.
16.	Unit Code: Enter employee's reporting unit number.
17.	Agency Name or System (if retired): Enter the name of the employee's department or agency.
18.	Remarks: As appropriate provide additional information in order to clarify the action being taken. Indicate the control period and hours worked during the six month qualifying control period for initial or re-enrollments of Permanent-Intermittent (PI) employees.
19.	Authorized Department Representative (Please Print)
20.	Authorized Agency Signature: Signature of an authorized department representative.
21.	Telephone Number with Area Code: Enter the telephone number of the authorized department representative. Including area code
22.	Date Received in Employing Office: Enter the date received in the employing office.
23.	Email Address: Enter email address.

Retiring Employees
1.	Employer Ded. Code:

•	CSU-150: For use by CSU only.
•	Non-CSU-351: N/A

2.	Dental Org. Code: Enter three digit dental plan code of plan employee is currently enrolled in.
3.	Party Code: Enter “1” for employee only; “2” for employee and one dependent; “3” for employee and two or more dependents.
4.	Pay Period*: N/A
5.	State Share Amount: Enter the amount of the State's contribution.
6.	Employee or CoBEN deduction amount: Enter amount of employee’s share of the premium to be deducted from employee’s retirement warrant. If amount is zero (i.e., for prepaid plans), leave blank.
7.	Employee Designation: N/A
8.	Bargaining Unit: N/A
9.	Total Premium Amount: Enter total amount of premium (Amounts from Items E5 + E6 = E9).
10.	Prior Employer Deduction Code

•	CSU-150: N/A
•	Non-CSU-351: N/A

11.	Prior Dental Org. Code & Party Code: N/A
12.	Permitting Event Date: Enter employee's retirement date.
13.	Permitting Event Code: N/A
14.	Effective Date of Action: The effective date is determined by whether the separation date is before or after the 10th of the month. (e.g., separation date is 4/8 and retirement date is 4/10 - effective date is 5/1; separation date is 4/15 and retirement date is 4/16 - effective date is 6/1.)
15.	Agency Code: N/A
16.	Unit Code: N/A
17.	Agency Name or System (if retired): Enter retirement system under which the employee will be retired (e.g., CalPERS Retired, Judges Retired, Legislative Retired).
18.	Remarks: Enter the separation and retirement date.
19.	Authorized Department Representative (Please Print)
20.	Authorized Agency Signature: Signature of an authorized department representative.
21.	Telephone Number with Area Code: Enter telephone number of the authorized department representative. Including area code.
22.	Date Received in Employing Office: Enter date document was completed.
23.	Email Address: Enter email address.

COBRA Continuation
1.	Employer Ded. Code

•	CSU-150: N/A
•	Non-CSU-351: N/A

2.	Dental Org. Code: Enter three digit dental plan code of plan eligible person is enrolled in.
3.	Party Code: Enter “1” for employee only; “2” for employee and one dependent; “3” for employee and two or more dependents.
4.	Pay Period*: (blank)
5.	State Share Amount: Enter the month and year enrollee lost coverage.
6.	Employee or CoBEN deduction amount: Enter total monthly premium to be paid by employee/eligible dependent(s).
7.	Employee Designation: N/A
8.	Bargaining Unit: N/A
9.	Total Premium Amount: Enter total amount of premium (should be same amount as E9).
10.	Prior Employer Deduction Code: N/A

•	CSU-150: N/A
•	Non-CSU-351: N/A

11.	Prior Dental Org. Code & Party Code: N/A
12.	Permitting Event Date: Enter the date of the qualifying COBRA event allowing the enrollment.
13.	Permitting Event Code: N/A
14.	Effective Date of Action: The effective date is the first of the month following the loss of dental coverage (e.g., enrollee loses coverage on 3/31; coverage would be effective 4/1).
15.	Agency Code: N/A
16.	Unit Code: N/A
17.	Agency Name or System (if retired): N/A
18.	Remarks: Enter the qualifying event allowing the COBRA enrollment (e.g. divorce, dependent turned age 26, etc.).
19.	Authorized Department Representative (Please Print)
20.	Authorized Agency Signature: Signature of an authorized department representative.
21.	Telephone Number with Area Code: Enter telephone number of the authorized department representative. Including area code.
22.	Date Received in Employing Office: Enter the date document was completed.
23.	Email Address: Enter email address.

DOCUMENT DISTRIBUTION
Active Employees
1. Original: White
•	Send to SCO

2. Second Copy: Yellow
•	Send to SCO

3. Third Copy: Pink
•	Retain in employee's personnel file

4. Fourth Copy: Green
•	Forward to employee

Retiring Employees
1. Original: White
•	Send to CalPERS

2. Second Copy: Yellow
•	Send to CalPERS

3. Third Copy: Pink
•	Retain in employee's personnel file

4. Fourth Copy: Green
•	Forward to retiring employee

COBRA Continuation
Original: White
•	Send to dental carrier

2. Second Copy: Yellow
•	Send to dental carrier

3. Third Copy: Pink
•	Retain in employee's personnel file

4. Fourth Copy: Green
•	Send to enrollee