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l Dental
Dental Coverage
PLAN HIGHLIGHTS:
key* 00431737 0001 E V16.0
HARRIS STOWE STATE UNIVERSITY
Here is your new coverage. Make sure you are aware of the deadline date for your coverage elections.
If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year.
Your Guardian plan number: 00431737
Learn more about Guardian atwww.guardianlife.com.
We’re ready to get working for youIf you’re like most employees, finding enough time in the day to accomplish your lengthyto-do list can often be no easy task.
As your Guardian coverage begins, we want you to know that we’re here for you every stepof the way and are committed to providing you with the resources to obtain fast, accurateanswers to your benefits-related questions.
One way in which we do this is through our online member resource, Guardian Anytimesm,which allows you to manage your benefits when it works best for you — day or night. Plus,it offers helpful resources to ensure you get access to the quality care you need.
We encourage you to take a couple minutes to check out and register for GuardianAnytimesm at www.GuardianAnytime.com. We promise it will be time well spent.
Welcome to Guardian!
Dental Plans YOUR GUARDIANPLAN OFFERS:Coverage of ViziLite Plusearly cancer detectionscreening exams
Maximum rollover If amember submits at leastone claim and stays underthe claims threshold, a partof the unused maximumwill be rolled over for usein future years.
Great selection of dentistsconvenient to you - yours islikely in our network!
Reliable claims payment fourdays on average
Find out if your dentist is inGuardians network atwww.GuardianAnytime.com
Let Guardian put its 30-plus yearsof dental benefits experience towork for you and your family.
Option 1: With your Managed Dental Care plan, you enjoy negotiated discounts from our network dentists. You pay a fixed copay for each coveredservice. Out-of-network visits are not covered.Option 2: With your PPO plan, you save money by visiting a PPO dentist. Out-of network visits are not covered.Option 3: With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits arebased on a percentile of the prevailing fee data for the dentist's zip code.
Benefit information illustrated within this material reflects the plan covered by Guardian as of 08/09/2018
Your Dental Plan Option 1: Managed DentalCare
Option 2: Guardian PPO(underwritten by The GuardianLife Insurance Company ofAmerica)
Option 3: Guardian PPO(underwritten by The GuardianLife Insurance Company ofAmerica)
Network First Commonwealth DentalGuard Preferred DentalGuard Preferred
Your Monthly premium $16.22 $24.51 $36.54You and 1 dependent (Spouse or Child) $32.50 $48.82 $72.41You, spouse/domestic partner and child(ren) $46.57 $79.30 $122.39
Plan year deductible In-Network Out-of-Network In-Network Out-of-NetworkIndividual No deductible $50 N/A $0 $50Family limit 3 per family 3 per familyWaived for Preventive Not applicable Not applicable Preventive
Charges covered for you (co-insurance) Network only In-Network Out-of-Network In-Network Out-of-NetworkPreventive Care You pay a copay for each 100% Not Covered 100% 100%Basic Care covered procedure. See 80% Not Covered 100% 80%Major Care Plan Details, for 50% Not Covered 60% 50%Orthodontia more information. Not Covered (applies to all levels) 50% 50%
Annual Maximum Benefit $0 N/A $1000 $1000
Maximum Rollover Maximum Rollover is not No YesRollover Threshold applicable for this plan type. $500Rollover Amount $250Rollover In-network Amount $350Rollover Account Limit $1000
Lifetime Orthodontia Maximum Not Applicable Not Applicable Not Applicable $1000
Office visit copay $5 None None
Dependent Age Limits(Non-Student/Student) 25/26 25/26 25/26
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Please note: The plandetails listed here are someof the most commonservices related to dentalcoverage. The co-insurance percentages forthe PPO plan optionscorrespond to the coveragecategories of Preventive,Basic, Major andOrthodontia listed in thetable above.
Please Note: For yourManaged Dental Care plan,coinsurances relate to afixed copayment amount,please refer to your planschedule.
Some services may be paidunder a different categorythan listed. The actualco-insurance shownreflects your plan'scoverage.
CATEGORY PLAN DETAILS Option 1: Managed DentalCare
Option 2: Guardian PPO(underwritten by TheGuardian Life InsuranceCompany of America)
Option 3: Guardian PPO(underwritten by TheGuardian Life InsuranceCompany of America)
Plan Pays (on average) Plan pays (on average) Plan pays (on average)
Network only In-network Out-of-network In-network Out-of-network
Preventive Care Cleaning (prophylaxis) 100% 100% Not Covered 100% 100%Frequency: Once every 6 months Once Every 6 Months Once Every 6 Months
Fluoride Treatments 100% 100% Not Covered 100% 100%Limits: No Age Limits No Age Limits No Age Limits
Oral Exams 100% 100% Not Covered 100% 100%Periodontal Maintenance 80% 100% Not Covered 100% 100%
Frequency: Once every 6 months (applies toall tiers)
Once Every 6 Months Once Every 6 Months
(Standard)Sealants (per tooth) 80% 100% Not Covered 100% 100%X-rays 100% 100% Not Covered 100% 100%
X-rays other than bitewings inBasic 80%
Basic Care Anesthesia* Not Covered 80% Not Covered 100% 80%Fillings 80% 80% Not Covered 100% 80%Root Canal 50-80% 80% Not Covered 100% 80%Scaling & Root Planing (per quadrant) 80% 80% Not Covered 60% 50%Simple Extractions 80% 80% Not Covered 100% 80%
Major Care Bridges and Dentures 50% 50% Not Covered 60% 50%Inlays, Onlays, Veneers** 50% 50% Not Covered 60% 50%Perio Surgery 50% 50% Not Covered 60% 50%Repair & Maintenance ofCrowns, Bridges & Dentures 50% 50% Not Covered 60% 50%Single Crowns 50% 50% Not Covered 60% 50%Surgical Extractions 50% 50% Not Covered 60% 50%
Orthodontia Orthodontia $1,000 Savings Not Covered 50% 50%Limits: Adults & Child(ren) Child(ren)
This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity members, Crowns,Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth cannot be restored with amalgam orcomposite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-timestatus is required by your in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. IfOrthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. *General Anesthesia - restrictions apply. For PPO and or Indemnity members, Fillings-restrictions may apply to composite fillings.This document is a summary of the major features of the referenced insurance coverage. It is intended for illustrative purposes only and does not constitute a contract. The
insurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description, including the benefits and all terms, limitationsand exclusions that apply will be contained in your insurance certificate. The plan documents are the final arbiter of coverage. Coverage terms may vary by state and actualsold plan. The premium amounts reflected in this summary are an approximation; if there is a discrepancy between this amount and the premium actually billed, the latterprevails.
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EXCLUSIONS AND LIMITATIONSn Important Information about Guardians DentalGuard Indemnity and DentalGuard Preferred Network PPO plans:
This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent,diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygieneservices (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic orexperimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payableby any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, andservices ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for preventive,restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listedabove do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter ofcoverage. Contract # GP-1-DG2000 et al.
n This policy provides dental coverage only. This policy provides managed care dental benefits through a network ofparticipating general dentists and specialty care dentists. Except for limited emergency services, benefits will be provided forservices provided by the primary care dentist selected by the member. The member must pay the primary care dentist apatient charge/copayment for most covered services. No benefits will be paid for treatment by a specialist unless the patientis referred by his or her primary care dentist and the referral is approved under the policy. Only those services listed in thepolicys schedule of benefits are covered. Certain services are subject to frequency or other periodic limitations. Whereorthodontic benefits are specifically included, the policy provides for one course of comprehensive treatment per member.Unless specifically included, the Managed Dental Care policy does not provide orthodontic benefits if comprehensive
orthodontic treatment or retention is in progress as of the members effective date under the Managed Dental Care policy.The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The applicableManaged Dental Care documents are the final arbiter of coverage .See your Certificate for complete specifics of allExclusions and Limitations. All products, unless otherwise noted, are underwritten by The Guardian Life. InsuranceCompany of America (Guardian) or one of the following wholly-owned Guardian subsidiaries: Managed Dental Care (CA);First Commonwealth Insurance Company (IL); First Commonwealth Limited Health Services Corporation (IN); FirstCommonwealth Limited Health Services Corporation of Michigan (MI); First Commonwealth of Missouri, Inc. (MO) andManaged DentalGuard, Inc. (NJ, OH and TX). Any reference to a specific product type, including but not limited to "DHMO"or Prepaid is not intended to refer to a specific state license designation, but rather is merely intended to refer to a generalproduct design. Such DHMO, or prepaid products, are licensed in the applicable jurisdiction. In addition, certain products areunderwritten by Dominion Dental Services, Inc. (DC, DE, MD, PA and VA) and LIBERTY Dental Plan of Nevada, Inc. (NV).Please see the applicable policy forms for details. In the event of conflict between this brochure and the policy forms, thepolicy forms shall control.
n For PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan.A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he becameinsured by this plan. We wont pay for a prosthetic device which replaces such teeth unless the device also replaces one ormore natural teeth lost or extracted after the covered person became insured by this plan.R3-DG2000
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Finding a dentist is easy
Go online – it just takes minutes! The best way to save money through your dental plan is by seeing a dentist in your plan’s network. Guardian’s Find a Provider site makes it easy for you to search for a dentist that meets your needs. Guardian’s Find a Provider site is available to you 24 hours a day, 7 days a week. • Customize your search by specialty, languages spoken and more • Get side-by-side comparisons of dentists’ information (ie. office status, distance) • Create a quick-list of “favorite” dentists — for easy reference online • Get maps and directions to a dentist’s office location • View your results online or have them faxed or emailed to you • Save your search criteria for easy access when you revisit the site • Create a customized directory of dentists • Nominate a dentist to be included in a network • And much more!
Just go to www.GuardianAnytime.com and click on “Find a Provider”. You can also find a dentist on the go from your smart phone – simply download our app.
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DH
MO
PLAN 3000 (M
O - $5 O
ffice Visit Copay)SCH
ED
ULE
OF M
EM
BER
S’ PAYME
NT R
ESPO
NSIBILITY
Effective as of 1/1/2016
MO-3000(5) 1/16R Page 1 of 2
DIA
GN
OST
ICD0999
Office Visit Copay........................................................................................................$5
D0120Periodic Oral Evaluation
..............................................................................................$0D0140
Limited Oral Evaluation - Problem
Focused...............................................................$0
D0145Oral Eval for Patient under 3 &
Counseling with Primary Caregiver..........................$0
D0150Com
prehensive Oral Evaluation - New or Established Patient...................................$0D0160
Detailed & Extensive Evaluation, Problem
Focused...................................................$0
D0170Re-Eval - Lim
ited, Problem Focused (Est. Patient, Not Post-Operative)....................$0
D0171Re-Evaluation - Post-Operative Office Visit................................................................$0
D0180Com
prehensive Periodontal Examination, New or Established Patient......................$0
D0210Intraoral - Com
plete Series (Incl. Bitewings)..............................................................$0D0220
Intraoral - Periapical First Film...................................................................................$0
D0230Intraoral - Periapical Each Additional Film
.................................................................$0D0240
Intraoral - Occlusal Film..............................................................................................$0
D0270Bitewing - Single Film
.................................................................................................$0D0272
Bitewing X-Rays - 2 Films...........................................................................................$0
D0273Bitewing X-Rays - 3 Film
s...........................................................................................$0D0274
Bitewing X-Rays - 4 Films...........................................................................................$0
D0277Vertical Bitewings - 7 to 8 Film
s.................................................................................$0
D0330Panoram
ic Film...........................................................................................................$0
D0415Bacteriological Studies................................................................................................$0
D0460Pulp Vitality Tests
........................................................................................................$0D0470
Diagnostic Casts..........................................................................................................$0
PR
EV
EN
TIV
ED1110
Prophylaxis - Adult......................................................................................................$0D1120
Prophylaxis - Child.....................................................................................................$0
D1206Topical Fluoride Varnish, Therapeutic Application for M
od to High Caries RiskPatients
........................................................................................................................$0D1208
Topical Application Of Fluoride - Excluding Varnish..................................................$0
D1310Nutritional Counseling for Control of Dental Disease
................................................$0D1330
Oral Hygiene Instructions............................................................................................$0D1351
Sealant - Per Tooth......................................................................................................$6
D1352Preventive Resin Restoration in M
od - High Caries Risk Patient - Perm Tooth
.........$6D1510
Space Maintainer - Fixed - Unilateral.......................................................................$34
D1515Space M
aintainer - Fixed - Bilateral..........................................................................$52D1520
Space Maint-Rem
ovable - Unilateral.........................................................................$34D1525
Space Maint-Rem
ovable - Bilateral...........................................................................$52D1550
Re-cement or Re-bond Space M
aintainer.................................................................$17D1555
Removal of a Space M
aintainer, By Dentist Who Did Not Originally Place
................$4
MIN
OR
RE
STO
RA
TIV
ED2140
Amalgam
- 1 Surface, Primary or Perm
anent...........................................................$12D2150
Amalgam
- 2 Surfaces, Primary or Perm
anent..........................................................$15D2160
Amalgam
- 3 Surfaces, Primary or Perm
anent..........................................................$18D2161
Amalgam
- 4 or More Surfaces, Prim
ary or Permanent............................................$21
D2330Resin-Based Com
posite - 1 Surface, Anterior..........................................................$15D2331
Resin-Based Composite - 2 Surfaces, Anterior........................................................$19
D2332Resin-Based Com
posite - 3 Surfaces, Anterior........................................................$22D2335
Resin-Based Comp - 4 or M
ore Surfaces or Involving Incisal Angle (Anterior)......$24D2390
Resin-Based Composite Crown, Anterior.................................................................$60
D2391Resin-Based Com
posite - 1 Surface, Posterior........................................................$44D2392
Resin-Based Composite - 2 Surfaces, Posterior.......................................................$56
D2393Resin-Based Com
posite - 3 Surfaces, Posterior.......................................................$68D2394
Resin-Based Composite - 4 or M
ore Surfaces, Posterior.........................................$72D2929
Prefabricated Porcelain/Ceramic Crown – Prim
ary Tooth........................................$75
D2990Resin Infiltration of Incipient Sm
ooth Surface Lesions...............................................$9
EN
DO
DO
NT
ICS
D3110Pulp Cap - Direct (Excluding Final Restoration).........................................................$7
D3120Pulp Cap - Indirect (Excluding Final Restoration)......................................................$7
D3220Therapeutic Pulpotom
y (Excluding Final Restoration).............................................$18D3221
Pulpal Debridement, Prim
ary & Perm
anent Teeth.....................................................$11D3222
Partial Pulpotomy for Apexogenesis – Perm
. Tooth with Incomplete Root..............$18
D3230Pulp Therapy, Anterior Prim
ary.................................................................................$47
D3240Pulp Therapy, Posterior Prim
ary...............................................................................$52
D3310Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)..........................$74
D3320Endodontic Therapy, Bicuspid Tooth (Excluding Final Restoration)
........................$93D3330
Endodontic Therapy, Molar (Excluding Final Restoration).....................................$324
D3351Apexification/Recalcification Initial Visit...................................................................$56
D3352Apexification/Recalcification Interim
Visit.................................................................$37D3353
Apexification/Recalcification Final Visit..................................................................$130D3410
Apicoectomy - Anterior............................................................................................$194
D3421Apicoectom
y - Bicuspid (First Root).......................................................................$235D3425
Apicoectomy - M
olar (First Root)............................................................................$242D3426
Apicoectomy (Each Additional Root).........................................................................$87
D3427Periradicular Surgery without Apicoectom
y............................................................$186D3430
Retrograde Filling - Per Root....................................................................................$53
D3450Root Am
putation Per Root.......................................................................................$110D3920
Hemisection (Incl. Root Rem
oval/Excludes Rct).....................................................$104D3950
Canal Prep & Fit of Preform
ed Post (By Other Than Dentist Who Placed Post)......$11
PE
RIO
DO
NT
ICS
D4210Gingivectom
y Or Gingivoplasty - 4 or More Teeth Per Quadrant...........................$151
D4211Gingivectom
y or Gingivoplasty - 1 to 3 Teeth, Per Quadrant...................................$55D4240
Gingival Flap Procedure, w/Root Planing - 4 or More Teeth Per Quadrant............$177
D4241Gingival Flap Procedure, w/Root Planing - 1 to 3 Teeth, Per Quadrant.................$112
D4212Gingivectom
y or Gingivoplasty to Allow Access For Restorative Procedure, PerTooth
..........................................................................................................................$39D4245
Apically Positioned Flap..........................................................................................$187D4249
Clinical Crown Lengthening - Hard Tissue.............................................................$223D4260
Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 4 or
More Teeth Per Quad
...............................................................................................$335D4261
Osseous Surgery (Incl. Elevation of a Full Thickness Flap & Closure) - 1 to 3
Teeth, Per Quad........................................................................................................$235D4268
Surgical Revision Procedure, Per Tooth, Inclusive in Surgery...................................$0
D4341Scaling &
Root Planing - 4 or More Teeth Per Quadrant..........................................$28
D4342Scaling &
Root Planing - 1 to 3 Teeth, Per Quadrant...............................................$20D4355
Full Mouth Debridem
ent to Enable Comprehensive Evaluation &
Diagnosis..........$12
D4381Loc. Deliv. Chem
o Agent, Controlled Release into Crevice, Per Tooth.......................$8D4910
Periodontal Maintenance...........................................................................................$17
D4921Gingival Irrigation - Per Quadrant...............................................................................$2
OR
AL SU
RG
ERY
D7111Extraction, Coronal Rem
nants - Deciduous Tooth......................................................$9
D7140Extraction, Erupted Tooth or Exposed Root (Elevation and/or Forceps Rem
oval)....$14D7210
Surg Removal of Erupted Tooth Requiring Rem
oval of Bone and/or Sectioning ofTooth; Inc. M
ucoperiosteal Flap if Indicated.............................................................$70
D7220Rem
oval of Impacted Tooth - Soft Tissue..................................................................$85
D7230Rem
oval of Impacted Tooth - Partially Bony
...........................................................$114D7240
Removal of Im
pacted Tooth - Completely Bony
......................................................$139D7241
Removal of Im
pacted Tooth - Completely Bony, with Unusual Surg Com
p...........$152
D7250Surgical Rem
oval of Residual Tooth Roots (Cutting Procedure)..............................$67D7280
Surgical Access of an Unerupted Tooth (Non-Orthodontic)...................................$139D7310
Alveoloplasty w/Extractions - Per Quadrant..............................................................$61D7311
Alveoloplasty w/Ext - 1 To 3 Teeth or Spaces, Per Quadrant....................................$50D7320
Alveoloplasty Not w/Extractions - Per Quadrant.......................................................$98D7321
Alveoloplasty Not w/Extractions - 1 to 3 Teeth or Spaces Per Quadrant..................$71D7450
Removal of Benign Odontogenic Cyst or Tum
or (Diameter 1.25 Cm
)..................$107D7510
Incision & Drainage of Abscess - Intraoral Soft Tissue
............................................$50D7511
Incision & Drainage of Abscess - Intraoral Soft Tissue - Com
plicated....................$29
D7960Frenulectom
y (Frenectomy or Frenotom
y) - Separate Procedure...........................$102D7963
Frenuloplasty...........................................................................................................$130D7972
Surgical Reduction of Fibrous Tuberosity.................................................................$67
CR
OW
NS
D2510Inlay - M
etallic - 1 Surface*....................................................................................$182
D2520Inlay - M
etallic - 2 Surfaces*..................................................................................$217
D2530Inlay - M
etallic - 3 or More Surfaces*
....................................................................$268D2542
Onlay - Metallic - 2 Surfaces*.................................................................................$245
D2543Onlay - M
etallic - 3 Surfaces*.................................................................................$288D2544
Onlay - Metallic - 4 or M
ore Surfaces*...................................................................$290D2610
Inlay - Porcelain Ceramic 1 Surf.............................................................................$207
D2620Inlay - Porcelain Ceram
ic 2 Surf.............................................................................$230D2630
Inlay - Porcelain Ceramic 3 Surf.............................................................................$429
D2642Onlay - Porcelain Ceram
ic 2 Surf............................................................................$260D2643
Onlay - Porcelain Ceramic 3 Surf............................................................................$291
D2644Onlay - Porcelain Ceram
ic 4+ Surf.........................................................................$311D2650
Inlay - Resin 1 Surf..................................................................................................$172D2651
Inlay - Resin 2 Surf..................................................................................................$190D2652
Inlay - Resin 3 Surf..................................................................................................$206D2662
Onlay - Resin 2 Surf................................................................................................$200D2663
Onlay - Resin 3 Surf................................................................................................$230D2664
Onlay - Resin 4+ Surf..............................................................................................$240D2710
Crown - Resin-Lab..................................................................................................$205
D2720Crown - Resin, High Noble M
etal*........................................................................$309
D2721Crown - Resin, Base M
etal......................................................................................$308D2722
Crown - Resin, Noble Metal...................................................................................$308
D2740Crown - Porcelain/Ceram
ic Substrate.....................................................................$323D2750
Crown - Porcelain Fused to High Noble Metal*
.....................................................$302D2751
Crown - Porcelain Fused to Predominantly Base M
etal.........................................$266D2752
Crown - Porcelain Fused to Noble Metal................................................................$297
D2780Crown - 3/4 Cast High Noble M
etal*......................................................................$323D2781
Crown - 3/4 Cast Predominantly Base M
etal.......................................................... $303D2782
Crown - 3/4 Cast Noble Metal................................................................................$299
D2783Crown - 3/4 Porcelain/Ceram
ic..............................................................................$323 11
*Designated restorations include high noble metal (gold). The actual cost of this metal may be added to the patient’s responsibility at the time ofservice. The payment responsibilities listed above are valid as of January 1, 2016. The payment responsibilities are subject to revision onJanuary 1 of each year. A complete description of benefits, limitations and exclusions is included in your subscription certificate.Current Dental Terminology © 2015 American Dental Association. All rights reserved.
DH
MO
PLAN 3000 (M
O - $5 O
ffice Visit Copay)
MO-3000(5) 1/16R Page 2 of 2
CR
OW
NS (cont.)
D2790Crown - Full Cast High Noble M
etal*.....................................................................$323
D2791Crown - Full Cast Predom
inantly Base Metal.........................................................$303
D2792Crown - Full Cast Noble M
etal................................................................................$196D2794
Crown - Titanium.....................................................................................................$323
D2910Re-cem
ent or Re-bond Inlay, Onlay, Veneer or Partial Coverage Restoration............$8
D2915Re-cem
ent or Re-bond Indirectly Fabricated or Prefabricated Post & Core...............$8
D2920Re-cem
ent or Re-bond Crown.....................................................................................$8D2930
Prefabricated Stainless Steel Crown - Primary Tooth
...............................................$69D2931
Prefabricated Stainless Steel Crown - Permanent Tooth...........................................$71
D2932Prefabricated Resin Crown
........................................................................................$75D2933
Prefabricated Stainless Steel Crown with Resin Window
..........................................$75D2934
Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth
.....................$75D2940
Protective Restoration................................................................................................$10D2941
Interim Therapeutic Restoration - Prim
ary Dentition..................................................$7
D2949Restorative Foundation for an Indirect Restoration
...................................................$32D2950
Core Buildup, Incl. any Pins When Required............................................................$58
D2951Pin Retention - Per Tooth, in Addition to Restoration...............................................$13
D2952Cast Post &
Core in Addition to Crown*................................................................$107
D2953Each Additional Cast Post - Sam
e Tooth*.................................................................$10D2954
Prefabricated Post & Core in Addition to Crown
......................................................$78D2957
Each Additional Prefabricated Post - Same Tooth.......................................................$7
D2971Additional Procedures to Construct New Crown Under Existing Partial..................$59
D2980Crown Repair.............................................................................................................$54
FIXE
D B
RID
GE
SD6205
Pontic - Indirect Resin Based Composite
...............................................................$205D6210
Pontic - Cast High Noble Metal*.............................................................................$323
D6211Pontic - Cast Predom
inantly Base Metal.................................................................$303
D6212Pontic - Cast Noble M
etal.......................................................................................$299D6214
Pontic - Titanium.....................................................................................................$323
D6240Pontic - Porcelain Fused to High Noble M
etal*......................................................$323D6241
Pontic - Porcelain Fused to Predominantly Base M
etal..........................................$244D6242
Pontic - Porcelain Fused to Noble Metal................................................................$291
D6245Pontic - Porcelain/Ceram
ic.....................................................................................$323
D6250Pontic - Resin, High Noble M
etal*..........................................................................$323D6251
Pontic - Resin, Base Metal......................................................................................$289
D6252Pontic - Resin, Noble M
etal....................................................................................$302D6545
Retainer - Cast Metal for Resin Bonded Fixed Prosthesis*
....................................$111D6548
Retainer - Porcelain for Resin Bonded Prosthesis..................................................$111D6549
Resin Retainer - for Resin Bonded Fixed Prosthesis................................................$55
D6600Retainer Inlay - Porcelain/Ceram
ic, Two Surfaces..................................................$230
D6601Retainer Inlay - Porcelain/Ceram
ic, Three or More Surfaces..................................$429
D6602Retainer Inlay - Cast High Noble M
etal, Two Surfaces*..........................................$217D6603
Retainer Inlay - Cast High Noble Metal, Three or M
ore Surfaces*.........................$268
D6604Retainer Inlay - Cast Predom
inately Base Metal, Two Surfaces..............................$217
D6605Retainer Inlay - Cast Predom
inately Base Metal, Three or M
ore Surfaces.............$268
D6606Retainer Inlay - Cast Noble M
etal, Two Surfaces....................................................$217
D6607Retainer Inlay - Cast Noble M
etal, Three or More Surfaces....................................$268
D6608Retainer Onlay - Porcelain/Ceram
ic, Two Surfaces.................................................$260D6609
Retainer Onlay - Porcelain/Ceramic, Three or M
ore Surfaces................................$291
D6610Retainer Onlay - Cast High Noble M
etal, Two Surfaces*........................................$245
D6611Retainer Onlay - Cast High Noble M
etal, Three or More Surfaces*........................$288
D6612Retainer Onlay - Cast Predom
inately Base Metal, Two Surfaces
............................$245D6613
Retainer Onlay - Cast Predominately Base M
etal, Three or More Surfaces............$288
D6614Retainer Onlay - Cast Noble M
etal, Two Surfaces...................................................$245D6615
Retainer Onlay - Cast Noble Metal, Three or M
ore Surfaces..................................$288
D6624Retainer Inlay - Titanium
.........................................................................................$217D6634
Retainer Onlay - Titanium........................................................................................$245
D6710Retainer Crown - Indirect Resin Based Com
posite.................................................$205
D6720Retainer Crown - Resin with High Noble M
etal*.....................................................$308D6721
Retainer Crown - Resin with Predominately Base M
etal.........................................$308D6722
Retainer Crown - Resin with Noble Metal...............................................................$308
D6740Retainer Crown - Porcelain/Ceram
ic.......................................................................$323D6750
Retainer Crown - Porcelain Fused to High Noble Metal*
.......................................$323D6751
Retainer Crown - Porcelain Fused to Predominately Base M
etal...........................$243D6752
Retainer Crown - Porcelain Fused to Noble Metal..................................................$291
D6780Retainer Crown - 3/4 Cast High Noble M
etal*........................................................$322D6781
Retainer Crown - 3/4 Cast Predominately Base M
etal............................................$303D6782
Retainer Crown - 3/4 Cast Noble Metal..................................................................$299
D6783Retainer Crown - 3/4 Porcelain/Ceram
ic................................................................$323
D6790Retainer Crown - Full Cast High Noble M
etal*.......................................................$323D6791
Retainer Crown - Full Cast Predominately Base M
etal...........................................$275D6792
Retainer Crown - Full Cast Noble Metal..................................................................$299
D6794Retainer Crown - Titanium
......................................................................................$323D6930
Re-cement or Re-bond Fixed Partial Denture
...........................................................$12D6980
Fixed Partial Denture Repair, by report......................................................................$55
LAB
IAL V
EN
EE
RS
D2960Labial Veneer (Resin Lam
inate) - Chairside............................................................$176D2961
Labial Veneer (Resin Laminate) - Lab
.....................................................................$199D2962
Labial Veneer (Porcelain Laminate) - Lab
...............................................................$268
DE
NT
UR
ES
D5110Com
plete Denture - Maxillary
.................................................................................$403D5120
Complete Denture - M
andibular..............................................................................$403D5130
Imm
ediate Denture - Maxillary
................................................................................$417D5140
Imm
ediate Denture - Mandibular............................................................................$417
D5211M
axillary Partial - Resin Base.................................................................................$268
D5212M
andibular Partial - Resin Base..............................................................................$268D5213
Maxillary Partial - Cast M
etal Framework w/Resin Bases.......................................$436
D5214M
andibular Partial - Cast Metal Fram
ework w/Resin Bases...................................$420D5221
Imm
ediate Maxillary Partial - Resin Base
...............................................................$281D5222
Imm
ediate Mandibular Partial - Resin Base............................................................$281
D5223Im
mediate M
axillary Partial - Cast Metal Fram
ework w/Resin Bases.....................$458D5224
Imm
ediate Mandibular Partial - Cast M
etal Framework w/Resin Bases
.................$440D5225
Maxillary Partial - Flexible Base..............................................................................$436
D5226M
andiublar Partial - Flexible Base.........................................................................$440D5281
Removable Unilateral Partial Denture......................................................................$210
D5410Adjust Com
plete Denture - Maxillary........................................................................$18
D5411Adjust Com
plete Denture - Mandibular....................................................................$18
D5421Adjust Partial Denture - M
axillary.............................................................................$18
D5422Adjust Partial Denture - M
andibular.........................................................................$18D5510
Repair Broken Complete Denture Base
.....................................................................$55D5520
Replace Missing or Broken Teeth - Com
plete Denture (Each Tooth)........................$43D5610
Repair Resin Denture Base........................................................................................$40
D5620Repair Cast Fram
ework..............................................................................................$41D5630
Repair or Replace Broken Clasp - Per Tooth.............................................................$51
D5640Replace Broken Teeth - Per Tooth
.............................................................................$33D5650
Add Tooth to Existing Partial Denture.......................................................................$44
D5660Add Clasp to Existing Partial Denture - Per Tooth
....................................................$57D5670
Replace All Teeth & Acrylic on Cast M
etal Framework - M
axillary......................... $174D5671
Replace All Teeth & Acrylic on Cast M
etal Framework - M
andibular.....................$174D5710
Rebase Complete M
axillary Denture.......................................................................$141
D5711Rebase Com
plete Mandibular Denture....................................................................$141
D5720Rebase M
axillary Partial Denture............................................................................$139
D5721Rebase M
andibular Partial Denture.........................................................................$139D5730
Reline Complete M
axillary Denture (Chairside)........................................................$78D5731
Reline Complete M
andibular Denture (Chairside)....................................................$78D5740
Reline Maxillary Partial Denture (Chairside).............................................................$71
D5741Reline M
andibular Partial Denture (Chairside).........................................................$71D5750
Reline Complete M
axillary Denture (Laboratory)....................................................$118D5751
Reline Complete M
andibular Denture (Laboratory)................................................$114D5760
Reline Maxillary Partial Denture (Laboratory).........................................................$107
D5761Reline M
andibular Partial Denture (Laboratory).....................................................$107D5850
Tissue Conditioning, Maxillary
.................................................................................$44D5851
Tissue Conditioning, Mandibular..............................................................................$44
ORT
HO
DO
NT
ICS
D8080Com
prehensive Orthodontic Treatment of the Adolescent Dentition (age 18 and
under) Class I and II............................................................................................$3,172D8090
Comprehensive Orthodontic Treatm
ent of the Adult Dentition (age 19 and over)Class I and II........................................................................................................$3,453
D8660Pre-Orthodontic Treatm
ent Examination to M
onitor Growth and Development.....$205
D8680Orthodontic Retention (Rem
oval of Appliances, Construction & Placem
ent OfRetainer(s))..............................................................................................................$260
D8681Rem
ovable Orthodontic Retainer Adjustment..............................................................$0
MISC
ELLA
NE
OU
SD9110
Palliative (Emergency) Treatm
ent of Dental Pain - Minor Procedure
.........................$9D9210
Local Anesthetic, Not in Conjunction with Operative Procs.......................................$0D9215
Local Anesthesia-In Conjunction with Operative or Surgical Procedures (Inclusivein those Procedures)...................................................................................................$0
D9230Analgesia, Nitrous Oxide.............................................................................................$5
D9310Consultation - Diagnostic Service Provided by Dentist or Physician Other ThanRequesting Dentist or Physician
...............................................................................$12D9430
Office Visit for Observation (During Regularly Scheduled Hours)..............................$5D9440
Office Visit for Observation (After Regularly Scheduled Hours).................................$5D9450
Case Presentation, Detailed & Extensive Treatm
ent Planning....................................$0
D9910Application of Desensitizing M
edicament, Per Visit...................................................$5
D9911Application of Desensitizing Resin for Cervical and/or Root Surface-Per Tooth........$6
D9951Occlusal Adjustm
ent - Limited
..................................................................................$11D9952
Occlusal Adjustment - Com
plete...............................................................................$28 12
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LOY
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DATE
FOR
MPU
BLISHED
:Aug
09,2018
TheGuardian
LifeInsurance
Company
ofAmerica
Enrollment/Change
FormPage
1of4
GuardianLife,P.O.Box
981585,ElPaso,TX
79998-1585
PlanAdm
inistrator:StephanieColem
an
Pleaseprintclearly
andm
arkcarefully.
qThe
GuardianLife
Insurancecom
panyofAm
ericaunderw
ritesgroup
termlife,accidentaldeath
anddism
emberm
ent,Shortterm
disability,Longterm
disability,criticalillness,dentalAndvision
coverages.
qFirstCom
monw
ealthofM
issouri,Inc.FirstCom
monw
ealthofM
issouri,Inc.underwrites
grouppre-paid
dentalcoverage
CE
F2015-RR
-MO
EmployerNam
e:HAR
RIS
STOW
ESTATE
UN
IVERSITY
GroupPlan
Number:00431737
BenefitsEffective:_____________
PLEASECHECK
APPROPRIATEBOX
qInitialEnrollm
entq
Re-Enrollment
qAdd
Employee/Dependents
qDrop/Refuse
Coverageq
Information
Change
qIncrease
Amount
qFam
ilyStatus
Change
Class:___________________Division:_________________
SubtotalCode:____________________(Ifapplicable,please
obtainthis
fromyourEm
ployer)
AboutYou:SocialSecurity
Number
First,MI,LastNam
e:___
______
-______
-______
______
AddressCity
StateZip
Gender:qM
qF
DateofBirth
(mm
-dd-yy):____-____
-____Phone:(
)-
EmailAddress:
Areyou
married
ordoyou
havea
spouse?q
Yes qNo
Dateofm
arriage/union:____-____-_____Do
youhave
childrenorotherdependents?
qYes q
NoPlacem
entdateofadopted
child:____-____-_____
AboutYourJob:Hours
worked
perweek:_______
JobTitle:
Work
Status:
qActive
qRetired
qCobra/State
ContinuationDate
offulltime
hire:____-____
-____
AboutYourFamily:
Pleaseinclude
thenam
esofthe
dependentsyou
wish
toenrollforcoverage.A
dependentisa
personthatyou,
asa
taxpayer,claim;w
horelies
onyou
forfinancialsupport;andforw
homyou
qualifyfora
dependencytax
exception.Dependency
taxexem
ptionsare
subjecttoIR
Srules
andregulations.Additionalinform
ationm
aybe
requiredfornon-standard
dependentssuch
asa
grandchild,aniece
oranephew
.Spouse
(First,MI,LastNam
e)
Address/City/State/Zip:
Phone:()
-
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Child/Dependent1:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Child/Dependent2:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
2
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MP
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Child/Dependent3:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Child/Dependent4:
Address/City/State/Zip:
Phone:()
-
qAdd
qDrop
Gender
qM
qF
SocialSecurityNum
ber
_____-_____
-_____
DateofBirth
(mm
-dd-yyyy)
____-____
-____
Status(check
allthatapply)q
Student(posthighschool)
qDisabled
qNon
standarddependent
Drop
Coverage:q
DropEm
ployeeq
DropDependents
Thedate
ofwithdraw
alcannotbepriorto
thedate
thisform
iscom
pletedand
signed.LastDay
ofCoverage:_____-_____-_____q
Termination
ofEmploym
entq
Retirement
LastDayW
orked:_____-_____-_____q
OtherEvent:_____________Date
ofEvent:_____-_____-_____
CoverageBeing
Dropped:
qDental
qEm
ployeeq
Spouseq
Child(ren)q
Visionq
Employee
qSpouse
qChild(ren)
qBasic
Lifeq
Employee
qSpouse
qChild(ren)
qVoluntary
Lifeq
Employee
qSpouse
qChild(ren)
qVAD&
Dq
Employee
qSpouse
qChild(ren)
qCriticalIllness
qEm
ployeeq
Spouseq
Child(ren)q
Accidentq
Employee
qSpouse
qChild(ren)
qCancer
qEm
ployeeq
Spouseq
Child(ren)q
Multi-Coverage
qLong
TermDisability
qShortTerm
Disability
LossO
fOtherCoverage:
Iand/ormy
dependentsw
erepreviously
coveredunderanotherinsurance
plan.Lossofcoverage
was
dueto:
qTerm
inationofEm
ployment:
_____-_____-_____q
Divorce_____-_____-_____
qDeath
ofSpouse_____-_____-_____
qTerm
ination/ExpirationofCoverage
_____-_____-_____Coverage
Lostq
Dentalq
Vision
Ihavebeen
offeredthe
abovecoverage(s)and
wish
todrop
enrollmentforthe
following
reasons:q
Coveredunderanotherinsurance
planq
Other____________________________________________________(additionalinform
ationm
aybe
required)
DentalCoverage:
Youm
ustbeenrolled
tocoveryourdependents.
Checkonly
onebox.
YourMonthly
Premium
Employee
OnlyEm
ployeeand
1Dependent
EE,Spouse&
Dependent/Child(ren)Option
1:Managed
DentalCare(underw
rittenby
FirstCom
monw
ealthofM
issouri,Inc.)q
$16.22q
$32.50q
$46.57
Option2:Guardian
PPO(underw
rittenby
TheGuardian
LifeInsurance
Company
ofAmerica)
q$24.51
q$48.82
q$79.30
Option3:Guardian
PPO(underw
rittenby
TheGuardian
LifeInsurance
Company
ofAmerica)
q$36.54
q$72.41
q$122.39
IfM
anagedDentalCare
coverageis
elected,youm
usthavea
Primary
CareDentist(PCD).Please
designateyourPCD(s)by
listingdentaloffice
locationnum
ber(s)foreachperson.Please
visitguardianlife.comfora
listofproviders.Ifyoudo
notselectaPCD,one
willbe
assignedforyou.
Employee
_________________________Spouse
_________________________Child(ren)_____________________________
qIdo
notwantthis
coverage.Ifyoudo
notwantthis
DentalCoverage,pleasem
arkallthatapply:
qIam
coveredunderanotherDentalplan
qM
yspouse
iscovered
underanotherDentalplanq
My
dependentsare
coveredunderanotherDentalplan
Signature
lIunderstand
thatmy
dependent(s)cannotbeenrolled
foracoverage
ifIamnotenrolled
forthatcoverage.
lIunderstand
thattheprem
iumam
ountsshow
nabove
areestim
ationsand
areforillustrative
purposesonly.
lSubm
issionofthis
formdoes
notguaranteecoverage.Am
ongotherthings,coverage
iscontingentupon
underwriting
approvalandm
eetingthe
applicableeligibility
requirements
assetforth
inthe
applicablebenefitbooklet.
GuardianGroup
PlanNum
ber:00431737Please
printemployee
name:
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ww
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ardianlife.com
3
lIfcoverage
isw
aivedand
youlaterdecide
toenroll,late
entrantpenaltiesm
ayapply.You
may
alsohave
toprovide,atyourow
nexpense,proofofeach
person'sinsurability.Guardian
oritsdesignee
hasthe
righttorejectyourrequest.
lPlan
designlim
itationsand
exclusionsm
ayapply.Forcom
pletedetails
ofcoverage,pleasereferto
yourbenefitbooklet.Statelim
itationsm
ayapply.
lIhereby
applyforthe
groupbenefit(s)thatIhave
chosenabove.
lIunderstand
thatImustm
eeteligibilityrequirem
entsforallcoverages
thatIhavechosen
above.
lIagree
thatmy
employerm
aydeductprem
iums
fromm
ypay
iftheyare
requiredforthe
coverageIhave
chosenabove.
lIacknow
ledgeand
consenttoreceiving
electroniccopies
ofapplicableinsurance
relateddocum
ents,inlieu
ofpapercopies,tothe
extentpermitted
byapplicable
law.I
may
changethis
electiononly
byproviding
thirty(30)day
priorwritten
notice.
lIattestthatthe
information
providedabove
istrue
andcorrectto
thebestofm
yknow
ledge.
Anyperson
who
with
intenttodefraud
anyinsurance
company
orotherpersonfiles
anapplication
forinsuranceorstatem
entsofclaim
containingany
knowingly,false
information,orconceals
forpurposeofm
isleadinginform
ationconcerning
anyfactm
aterialhereto,comm
itsa
fraudulentinsuranceact,w
hichis
acrim
e,andm
ayalso
besubjectto
civilpenalties,ordenialofinsurancebenefits.
Thestate
inw
hichyou
residem
ayhave
aspecific
statefraud
warning.Please
refertothe
attachedFraud
Warning
Statements
page.
Thelaw
sofNew
Yorkrequire
thefollow
ingstatem
entappear:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesan
applicationforinsurance
orstatementofclaim
containingany
materially
falseinform
ation,orconcealsforthe
purposeofm
isleading,information
concerningany
factm
aterialthereto,comm
itsa
fraudulentinsuranceact,w
hichis
acrim
e,andshallalso
besubjectto
acivilpenalty
nottoexceed
fivethousand
dollarsand
thestated
valueofthe
claimforeach
suchviolation.(Does
notapplyto
LifeInsurance.)
SIGNATUREOF
EMPLOYEE
X___________________________________________
DATE______________________
EnrollmentKit
00431737,0001,EN
FraudW
arningStatem
ents
Thelaw
sofseveralstates
requirethe
following
statements
toappearon
theenrollm
entform:
Alabama:Any
personw
hoknow
inglypresents
afalse
orfraudulentclaimforpaym
entofaloss
orbenefitorwho
knowingly
presentsfalse
information
inan
applicationfor
insuranceis
guiltyofa
crime
andm
aybe
subjecttorestitution
finesorconfinem
entinprison,orany
combination
thereof.
Arizona:ForyourprotectionArizona
lawrequires
thefollow
ingstatem
enttoappearon
thisform
.Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpayment
ofaloss
issubjectto
criminaland
civilpenalties.
California:ForyourprotectionCalifornia
lawrequires
thefollow
ingto
appearonthis
form:Any
personw
hoknow
inglypresents
falseorfraudulentclaim
forthepaym
entofaloss
isguilty
ofacrim
eand
may
besubjectto
finesand
confinementin
stateprison.
Colorado:Itisunlaw
fultoknow
inglyprovide
false,incomplete,orm
isleadingfacts
orinformation
toan
insurancecom
panyforthe
purposeofdefrauding
orattempting
todefraud
thecom
pany.Penalties
may
includeim
prisonment,fines,denialofinsurance,and
civildamages.
Anyinsurance
company
oragentofaninsurance
company
who
knowingly
providesfalse,incom
plete,ormisleading
factsorinform
ationto
apolicy
holderorclaimantforthe
purposeofdefrauding
orattempting
todefraud
thepolicy
holderorclaimantw
ithregard
toa
settlementoraw
ardpayable
frominsurance
proceedsshallbe
reportedto
theColorado
DivisionofInsurance
within
theDepartm
entofRegulatory
Agencies.
Connecticut,Iowa,Kansas,Nebraska,Oregon,and
Vermont:Any
personw
hoknow
ingly,andw
ithintentto
defraudany
insurancecom
panyorotherperson,files
anapplication
ofinsuranceorstatem
entofclaimcontaining
anym
ateriallyfalse
information
orconceals,forthepurpose
ofmisleading,inform
ationconcerning
anyfactm
aterialthereto,m
aybe
guiltyofa
fraudulentinsuranceact,w
hichm
aybe
acrim
e,andm
ayalso
besubjectto
civilpenalties.
Delaware,Indiana
andOklahom
a:WARNING:Any
personw
hoknow
ingly,andw
ithintentto
injure,defraudordeceive
anyinsurer,m
akesany
claimforthe
proceedsofan
insurancepolicy
containingany
false,incomplete
ormisleading
information
isguilty
ofafelony.
DistrictofColumbia:W
ARNING:Itisa
crime
toprovide
falseorm
isleadinginform
ationto
aninsurerforthe
purposeofdefrauding
theinsurerorany
otherperson.Penaltiesinclude
imprisonm
entand/orfines.Inaddition,an
insurermay
denyinsurance
benefits,iffalseinform
ationm
ateriallyrelated
toa
claimw
asprovided
bythe
applicant.
Florida:Anyperson
who
knowingly
andw
ithintentto
injure,defraud,ordeceiveany
insurerfilesa
statementofclaim
oranapplication
containingany
false,incomplete,or
misleading
information
isguilty
ofafelony
ofthethird
degree.
Kentucky:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesa
statementofclaim
containingany
materially
falseinform
ationorconceals,forthe
purposeofm
isleading,information
concerningany
factmaterialthereto
comm
itsa
fraudulentinsuranceact,w
hichis
acrim
e.
Louisianaand
Texas:Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpaymentofa
lossorbenefitis
guiltyofa
crime
andm
aybe
subjecttofines
andconfinem
entsin
stateprison.
Maine,Tennessee,Virginia
andW
ashington:Itisa
crime
toknow
inglyprovide
false,incomplete
ormisleading
information
toan
insurancecom
panyforthe
purposeof
defraudingthe
company.Penalties
may
includeim
prisonment,fines
oradenialofinsurance
benefits.
Maryland
andRhode
Island:Anyperson
who
knowingly
andw
illfullypresents
afalse
orfraudulentclaimforpaym
entofaloss
orbenefitorknowingly
andw
illfullypresents
falseinform
ationin
anapplication
forinsuranceis
guiltyofa
crime
andm
aybe
subjecttofines
andconfinem
entinprison.
4
Minnesota:A
personw
hofiles
aclaim
with
intenttodefraud
orhelpscom
mita
fraudagainstan
insurerisguilty
ofacrim
e.
NewHam
pshire:Anyperson
who,w
itha
purposeto
injure,defraudordeceive
anyinsurance
company,files
astatem
entofclaimcontaining
anyfalse,incom
pleteor
misleading
information
issubjectto
prosecutionand
punishmentforinsurance
fraud,asprovided
inN.H.Rev.Stat.Ann.§
638:20
NewJersey:Any
personw
hoknow
inglyfiles
astatem
entofclaimcontaining
anyfalse
ormisleading
information
issubjectto
criminaland
civilpenalties.
NewM
exico:Anyperson
who
knowingly
presentsa
falseorfraudulentclaim
forpaymentora
lossorbenefitorknow
inglypresents
falseinform
ationin
anapplication
forinsurance
isguilty
ofacrim
eand
may
besubjectto
civilfinesand
criminalpenalties
ordenialofinsurancebenefits.
Ohio:Anyperson
who
with
intenttodefraud
orknowing
thathe/sheis
facilitatinga
fraudagainstan
insurer,submits
anapplication
orfilesa
claimcontaining
afalse
ordeceptive
statementis
guiltyofinsurance
fraud.
Pennsylvania:Anyperson
who
knowingly
andw
ithintentto
defraudany
insurancecom
panyorotherperson
filesan
applicationforinsurance
orstatementofclaim
containingany
materially
falseinform
ationorconceals
forthepurpose
ofmisleading,inform
ationconcerning
anyfactm
aterialtheretocom
mits
afraudulentinsurance
act,w
hichis
acrim
eand
subjectssuch
personto
criminaland
civilpenalties.
Thank You
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Date form submitted:
© 2005 The Guardian Life Insurance Company of America,7 Hanover Square, New York 10004
Make the most of your Guardian benefits atwww.GuardianAnytime.com
Enrolled members and their dependents can access helpful,secure information about their Guardian benefit(s) instantly atwww.GuardianAnytime.com
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