Verification Agreement

I confirm that I provided correct personal and contact information about the Primary Policy holder such as name, address, date of birth, gender, phone number, email, and Social Security Number.

If purchasing  a Single +1 or Family plan: I acknowledge that I provided correct personal information about the dependents in this plan such as name, and date of birth. Dependents will also be enrolled for coverage under the same policy as the primary policy holder.

I understand that I am purchasing a Smart Health Dental PPO policy offered through the C.A. Association.

I understand the total to be billed today, which includes a one-time non-refundable enrollment fee of $10 and will be billed on the:  credit card or bank account that I provided and that the name of the billing entity is Smart Health Dental, LLC. 

I understand the ongoing monthly payment and that this includes your dental policy premium, $1 association membership fee, $4 processing fee, and $4 coordination and materials fees, and that the monthly total will be billed automatically each month on a recurring basis unless cancelled. 

I understand that once the initial payment is approved, the policy will become effective on the date provided. (Effective Date Rule: Paid enrollments between the 1st and 15th of the current month become effective on the 1st of the following month – Paid enrollments on the 16th – 31st of the current month, become effective on the 15th of the following month).

I understand that I have selected a Smart Health Dental – PPO policy which is underwritten by Renaissance Life & Health Insurance Company, except for members who live in New York. If the primary member lives in New York: the policy is underwritten by Renaissance Health Insurance Company of New York. You are also entitled to coordination services and non insurance discounts through your C.A. association membership. 

I understand that once enrolled, the policy and rates are effective for 12 consecutive months from the effective date, as long as premium payments are made on time and all other conditions of the policy are met. After the first 12 months the policy will automatically renew for an additional 12-month period upon payment of the renewal premium, unless Smart Health Dental declines to renew the policy or I decide not to renew it, according to the terms of the policy. 

I understand that I have a “free look” period of 30 days and that during this “free look” period, I can cancel the policy in writing and receive a full refund excluding the one-time enrollment fee, as long as I do not use the benefits? I also understand that the dental policy MUST be cancelled SEPARATELY from any other health insurance policies I may have purchased at the same time. 

If purchasing the Comprehensive Elevate Plan: I understand that the policy I am purchasing has an annual maximum of $750 per covered person in the first year and that coverage percentages and annual maximums for dental services on this insurance policy increase year after year in the first three years as they are outlined on your policy certificate. I also understand that for non-covered procedures, including Orthodontics, I have access to the Elite Care Coordinators who will help me find a dentist, book an appointment, and assist me in confirming the lowest available rate for any procedure. Although Smart Health Dental cannot guarantee specific savings, the coordination services typically result in an average savings of 20% – 50% off the usual rate for a geographic area. Lastly, I understand that there is a benefit year deductible of $50 per person, or $150 per family, that applies to all services except Diagnostic and Preventative services.

If purchasing the Preventive PPO Plan: I understand that this policy has an annual maximum of $750 per covered person and that major
dental services are not covered by this insurance policy and are shown to be covered at 0% on your policy certificate. I also understand that for non-covered procedures, I have access to the Elite Care Coordinators who will help me find a dentist, book an appointment, and assist me in confirming the lowest available rate for any procedure. Although Smart Health Dental cannot guarantee specific savings, the
coordination services typically result in an average savings of 20% – 50% off the usual rate for a geographic area. I understand that you are responsible for payment of the coordinated rate for major dental services.

Mandatory fraud disclosures: 

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

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a certificate holder or claimant for the purpose of defrauding or attempting to defraud the policy or certificate holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department regulatory agencies. 

DC: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. 

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. 

Kentucky/Ohio: I understand that any person who, with intent to defraud, or knowing that he or she is facilitating a fraud against an insurer, submits an application containing a false or deceptive statement is guilty of insurance fraud. 

Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefit. 

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. 

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. 

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. 

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto omits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 

Tennessee/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. 

Required California notice: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. 

ALL OTHER STATES: 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. 

I acknowledge that I understand the above disclosures.