Maryland

APPLICATION FOR DENTAL INSURANCE

GOLDEN RULE INSURANCE COMPANY
INDIANAPOLIS, INDIANA 46278-1719

Please list only those persons needing coverage.

Applicant(s) Information

Gender Name (Last, First, M.I.) Birth Date

✔ Male
 07
 Female Primary (You) (must be age 18-64) Boceanu Marian 04 80

 Male
 Female Spouse/Domestic Partner
✔ Male
 12
 Female Child 1 Alexandru Emir rares 24 17

 Male
 Female Child 2
 Male
 Female Child 3
 Male
 Female Child 4
 Male
 Female Child 5
 Male
 Female Child 6

Resident Physical Address (where you live and pay taxes). PO Boxes are not accepted.
Street (Include Apt.) City State ZIP Code
2801 QUANTICO AVE BALTIMORE MD 2 1 2 1 5

Mailing Address (if different than Resident Address)

Street (Include Apt.) City State ZIP Code

Explain why the mailing address is different than the resident physical address: ______________________________________________________
_____________________________________________________________________________________________________________________

Payor (if not you)

Name (Last, First, M.I.):

Street (Include Apt.) City State ZIP Code

DEN-AP-181-GRI-19 Page 1 787F-G-0523

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 Contact Information
Phone Number Email
Primary (You) 360 857-8037 [email protected]
Spouse/Domestic
Partner
Dependent Child age
18 and over
Dependent Child age
18 and over
Payor (if not you) -

Your Beneficiary: You will be the beneficiary for your

Name Relationship Date of Birth spouse/domestic partner.

Plan Selection

Requested Effective Date: ____/____/_____

09 29 2023 (See Statement of Understanding section)

Plans
 Premier Choice - $1,500 calendar year maximum
(Choose One)
 Premier Elite - $2,000 calendar year maximum
 Premier Plus - $2,000 calendar year maximum, $1,000 orthodontic lifetime maximum
 Premier Max - $3,000 calendar year maximum
✔
 Primary - $1,000 calendar year maximum
 Primary Plus - $1,000 calendar year maximum
 Primary Preferred - $1,000 calendar year maximum
 Primary Preferred Plus - $1,000 calendar year maximum
 Essential - $1,000 calendar year maximum
 Essential Preferred - $1,000 calendar year maximum
Optional  Vision
Initial Payment
Estimated Monthly Premium $ 64.16
_________________________________________________________________________________________________

Initial Monthly Payment with Application $ 64.16

DEN-AP-181-GRI-19 Page 2 787F-G-0523

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 Statement of Understanding
I have read this application and represent that the information shown on it is true and complete. I understand and agree that:
(1) No insurance will become effective unless my application is approved and the appropriate premium is actually received by Golden Rule
Insurance Company (GRIC) with this application.
(2) If other dental/vision insurance exists that duplicates coverage under the dental/vision plan being applied for, existing dental/vision coverage
must be terminated prior to the effective date of this coverage.
(3) The primary applicant must be age 18-64 to be eligible for coverage.
(4) If coverage is issued, the coverage will not be a continuation of any prior coverage.
(5) Incorrect or incomplete information in this application may result in voidance of coverage and claim denial.
(6) The information provided in this application, and any supplement or amendments to it, will be made a part of any policy or policies that may be
issued.
(7) An application, if approved, will be effective the later of:
(a) The requested effective date; or
(b) The day after receipt by GRIC or if mailed, the day after the postmark date.
(8) The producer is only authorized to submit the application and initial premium and may not change or waive any right or requirement.
(9) If GRIC rejects this application, under no circumstances will any benefits be payable. Receipt of payment by GRIC does not constitute approval
of my application or create GRIC coverage.
(10) I have received a Notice of Privacy Practices and a Conditional Receipt or Conditions Prior to Coverage.
(11) For any applicant who is eligible for Medicare, I acknowledge that applicant has access to/has received a Guide to Health Insurance for People
with Medicare. The Guide to Health Insurance for People with Medicare is available at:
https://stage.uhone.com/api/supplysystem/?Filename=Medicare-Medigap-guide.pdf
(12) THIS IS NOT A MEDICARE SUPPLEMENT POLICY.
(13) The policy being applied for may contain waiting periods for certain benefits listed on the policy Data Page.

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Signature Information
Signature Date Signed
Primary Applicant (or Parent/Legal Guardian if
Primary Applicant is a minor) Marian Boceanu (esign) 09 28 23

DEN-AP-181-GRI-19 Page 3

Final Authorizations
Producer Statement – Review the completed application before signing below.
Each question on the application was completed by the applicant(s). The applicant has received a Notice of Privacy Practices and a Conditional
Receipt or Conditions Prior to Coverage.
X X Unitedhealthone Direct Sales
Signature of Licensed Producer Print Full Name

4005234
Producer Number

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 IMPORTANT NOTICE TO PERSON ON MEDICARE
THIS INSURANCE DUPLICATES
SOME MEDICARE BENEFITS

This is not Medicare Supplement Insurance

This insurance provides limited benefits, if you meet the policy conditions, for expenses relating to the
specific services listed in the policy. It does not pay your Medicare deductibles or coinsurance and is not
a substitute for Medicare Supplement insurance.

This insurance duplicates Medicare benefits when:

• any of the services covered by the policy are also covered by Medicare

Medicare pays extensive benefits for medically necessary services regardless of the reason you need
them. These include:

• hospitalization

• physician services

• outpatient prescription drugs if you are enrolled in Medicare Part D

• other approved items and services

Before You Buy This Insurance

Check the coverage in all health insurance policies you already have.

For more information about Medicare and Medicare Supplement insurance, review the Guide to Health
Insurance for People with Medicare, available from the insurance company.

For help in understanding your health insurance, contact your state insurance department or state health
insurance assistance program SHIP.
45574-X-19-0918

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Payment
Payment Method – Select One Below
 EFT – Complete EFT Authorization below
✔ Credit Card – Complete Credit Card Authorization below


Electronic Funds Transfer (EFT) and Credit Card payments will be collected at the time of application. Premium will be verified and may be adjusted
up or down during the processing of your application.

 ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION – ONLY IF PAYING BY EFT:

I (we) hereby authorize Golden Rule Insurance Company to initiate debit entries to the account
indicated below. I also authorize the named financial institution to debit the same to such
account.
I agree this authorization will remain in effect until you actually receive written notification of its
termination from me.
Type of Account:  Checking  Savings

Nine-digit Routing No. Account No.

Financial Institution’s Name

Address

City, State, ZIP

Draft On
Day Date Signed
Only select a draft date between the 1st and 28th of the month.
In Tennessee and Texas, drafts may only be scheduled on 1) the premium due date; or 2) up to 10 days after the due date.
X ___________________________________________________________
Authorized Account Signature

✔ CREDIT CARD AUTHORIZATION – ONLY IF PAYING BY CREDIT CARD:


I authorize Golden Rule Insurance Company to bill my MasterCard/Visa/American Express/Discover account.

Type of Card:  MasterCard  Visa  American Express  Discover Exp Date 05 2027
Month Year

Billing ZIP Code: Card Number:

X ________________________________________________________
Marian Boceanu (esign)Authorized User 10
Charge On __________________
Signature of Authorized User Day
Only select a charge date between the 1st and 28th of the month.

NOTE: Some card issuers/financial institutions charge cash advance fees on insurance payments.

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 CONSENT TO RECEIVE ELECTRONIC RECORDS AND
TO CONDUCT TRANSACTIONS ELECTRONICALLY

By submitting this consent form or a health insurance application or HMO enrollment form, you hereby
consent to presentation, delivery, storage retrieval and transmission of “Communications” related to “Our
Transaction” as electronic records instead of in paper form.
For the purposes of this form, “Our Transaction” means the entirety of the business relationship between you
and us. “Communications” includes, but is not limited to:
1. Your application or enrollment form, including subsequent amendments;
2. Information related to Our Transaction that we are required to provide or make available in writing such as
privacy notices or fraud warnings;
3. Documents related to Our Transaction such as policy, certificate, or evidence of coverage forms, claim
forms, explanation of benefit forms, premium notices or privacy policies and notices (e.g., HIPAA Notices
or Privacy Practices) or other administrative forms (to the extent permitted by applicable law);
4. Any emails, faxes, recorded telephone calls, or other electronic transmissions of information between you
and us and an insurance producer contracted with us, or between us and any third party.
Subject to our obligations to protect your privacy, we may, at our sole discretion, post Communications on a
website (in which case they will be sent or received, as the case may be, regardless of whether or not we
own, operate or control the website). Or send them in or attached to an email. Please be advised that
communication by unencrypted email presents a risk of disclosure to, or interception by, unintended third parties.
You must promptly tell us about any change to your electronic or physical mailing address, or other contact
information.
You acknowledge that you can receive or access Communications because you have the following:
• A telephone
• A computer and printer
• A device or computer program for listening to audio CDs, mp3, WAV or other common computer audio files
• An Internet browser
• Access to the Internet
• A valid email address
• Adobe Acrobat Reader or other sufficient PDF reader
You can request a free copy of any Communications, or withdraw your consent to receive
electronic Communications at any time by sending a written request to:
Policy Administration
PO Box 31372
Salt Lake City, UT 84131-0372
✔ I hereby consent to receive Communications and Transaction Documents electronically, as per the
aforementioned conditions. All of the Communications between the time you submit your consent and
withdraw your consent will remain valid and binding on both you and us notwithstanding your withdrawal.
I hereby DO NOT consent to receive Communications and Transaction Documents electronically,
as per the aforementioned conditions. If you do not consent, we will conduct all future business with
you in paper form.
Marian Boceanu (esign)
X ______________________________________________ X _______________________________________________
Parent/Guardian (if you are a minor) Relationship

[email protected]
______________________________________________ ______________________________________________
Primary Applicant (You) Email Address Parent/Guardian (if you are a minor) Email address

09 28 23
______________________________________________ 442188294
______________________________________________
Date Policy ID Number

44177a-X-1020
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•
a I MARYLAND
Health Care Randolph S. Sergent, Esq., Chairman
I.I ,II Commission Ben Steffen, Execu tive Di rector

Your Life,
Your Decisions
Advance Directives Information Sheet
Regardless of age or health status, a medical crisis could leave you too ill or injured to communicate decisions about your
health care. Thinking about the types of treatment you would or wouldn’t like and potential outcomes is important before
a medical crisis occurs. Start the conversation with family, friends, health care providers, an attorney, or religious advisor.

ADVANCE CARE PLANNING – DISCUSS

Advance care planning is an ongoing conversation with people you trust to discuss your personal preferences and decisions
that might need to be made in a medical crisis, not just end-of-life care. Advance care planning requires careful
consideration of your values, religious beliefs, preferences for treatment, and acceptable outcomes, which are documented
in an advance directive or a Medical Orders for Life-Sustaining Treatment (MOLST) form. An advance directive is not the
same as a MOLST form; to learn more about the Maryland MOLST form, visit marylandmolst.org. These conversations
make your wishes known so they can be honored in the event you have limited or no capacity to make decisions for
yourself. This eases burden on family and loved ones and helps prevent conflicts about your care. Identifying who can
speak on your behalf is important – in Maryland, this individual is called a health care agent. If you don’t appoint a health
care agent, your next of kin will be designated under law to make decisions for you if you can’t speak for yourself.

ADVANCE DIRECTIVE – RECORD

You have the option to create an advance directive, a useful and legal way to direct your medical care when you can’t speak
for yourself. You can appoint a health care agent to make decisions on your behalf and specify your treatment preferences
in future situations, such as when to use life-sustaining treatments. Pick someone you trust to make these serious decisions
and talk to that person to make sure they accept the responsibility. Include their name and contact information and any
back-up health care agents in your advance directive. Various advance directive forms are available from health care
providers, religious organizations, estate planners, lawyers, and others. There is no one form that must be used; you can
personalize your advance directive to fit your wishes. Make sure to provide a copy of your advance directive to your family,
health care providers, lawyer, or anyone else who should be aware of your decisions. Remember − you are not required to
have an advance directive, and you can revoke your advance directive and complete a new one at any time.

ELECTRONIC DOCUMENTATION – SHARE

An advance directive can be most effective if you make it available in electronic form that is easily accessible by a health
care provider. Talk to your health care provider about storing a copy of your advance directive and health care agent
information in their secure electronic health record system. You may be able to add and update this information outside
of clinical visits using the health care provider’s patient portal, a secure online website where you can view your health
record and communicate with your care team. You can also use a State Recognized electronic advance directives service to
create, upload, share, and update your advance directive and health care agent information; learn more about how health
care providers involved in your care can access your information at crisphealth.org/for-patients/#advance-directives.

More information about how to get started with your advance directive, including sample forms, is available on the Maryland Attorney
General’s website: www.marylandattorneygeneral.gov/Pages/HealthPolicy/AdvanceDirectives.aspx

mhcc.maryland.gov December 2022

Toll Free: 1-877-245-1762 mhcc.maryland.gov
TTY Number: 1-800-735-2258 4160 Patterson Avenue