Please print this form WOLFPACK DELTA CARE APPLICATION	Agent Information: I.D. #22185
Mail to: Wolfpack Insurance Services, Inc. 800-296-0192 CA License 0814789	Agent Name: Lee Martinson
Small Business Benefit Plan Trust Plan	Agent Address: PO Box 950, Yucaipa, CA 92399
P. O. Box 156 Belmont CA 94002	Agent Phone # (909) 790-8622

DeltaCare from PMI Dental Health Plan

This is a dental HMO Program. You and your family must receive all treatment from the DeltaCare dental office you select.

Please indicate the number of the DeltaCare office you have chosen: #_________________

Provider Name ___________________________________________________________

Rates for Calendar year 2006:
Enrollment type	Monthly (Automatic deduction)	Quarterly (Payment by check)
One Person	$29.60	$88.80
Two Persons	$52.20	$156.60
Three Persons or more	$76.80	$230.40

Select Your Payment Option:
     ___ Monthly (Automatic) Please include a check for the first months premium plus a $5.00 enrollment fee with this application.
     ___ Quarterly (Payment by check), Please include a check for the first Quarters premium payment, a $5.00 enrollment fee and a $3.00 billing fee.
     ___ Employer list bill: Please include the monthly premium for all enrollees, a $5.00 enrollment fee for each member and a $5.00 billing fee.
            Employer Name:__________________________________________   Employer address ___________________________________________________________
            Employer Contact: ________________________________________    Employer Phone Number: _____________________________________

Enrollee Mailing Address City State Zip
Enrollee Social Security Number:	Phone Number

	First Name	Last Name	Male or Female	Date of Birth
Enrollee
Spouse
Child
Child
Child
Child

Automatic payment authorization
I (we) hereby authorize PMI to charge the applicable monthly dues for dental coverage to my account designated below. I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction. I understand eligibility begins the first of the month following my initial deduction. This authority to deduct funds from my account is to remain in full force and effect until I notify PMI in writing 30 days prior to termination. I also understand there cannot be any lapse in coverage in a 12-month period from the time of my enrollment. I agree to comply with the terms outlined in the Combined Evidence of Coverage and Disclosure Form. (My bank is authorized to make corrections if any should be necessary.)
_____ Checking Account _____ Savings Account (Please enclose a voided check or preprinted deposit slip from the account checked if it is different that the account you are using for the first months premium payment.)

Bank or savings and loan name _______________________________________________________________________
Branch ___________________________ Branch Telephone Number _______________________________
City State ________________________________________________ Zip Code ______________________
ABA (Bank routing #) __ __ __ __ __ __ __ __ __ Account Number _____________________________________
Please verify your account information with your bank

Signature of enrollee ____________________________ Date _____________________________

Note: The enrollment information must be received at the latest by the 15th of the month for coverage to begin the 1st of the following month. Incomplete. inaccurate information will cause a delay in your enrollment into the program
Rates of all applicants that enroll January 1, 2006 through December 1, 2006 are pool rated and will renew January 1, 2007.