To submit the Dental Enrollment/Change Form, fax the completed document to ARSEBA at (501) 663-1445. Alternatively, you can send the form via email to benefits@arseba.com. For physical submission, mail the form to Arkansas State Employees Benefit Advisors, 1301 West 7th Street, Little Rock, AR 72201. Ensure you keep a copy of the submitted form for your records.

Important enrollment dates for 2024 and 2025 are outlined in the agency announcements. For 2024, open enrollment typically occurs in December, with coverage commencing January 1st. For 2025, be sure to check announcements for similar timelines to ensure you don't miss your opportunity.

The purpose of the Dental Enrollment/Change Form is to facilitate Arkansas state employees in enrolling or altering their current dental benefits. This form assists in accurately capturing personal details and selecting appropriate coverage options based on individual or family needs. By using this form, employees can effectively manage their dental insurance in accordance with life events and agency requirements.

• 1. Agency Name: The name of the agency for which the employee works.
• 2. Last Name: The last name of the employee.
• 3. SSN: Social Security Number of the employee.
• 4. Effective Date: The date the coverage will take effect.
• 5. First Name: The first name of the employee.
• 6. MI: Middle initial of the employee.
• 7. Personnel Number: Employee ID number.
• 8. Street Address: Current residential address of the employee.
• 9. City: City of residence.
• 10. State: State of residence.
• 11. Email: Email address for communication purposes.
• 12. Date of Hire: Employment start date.
• 13. Gender: Gender of the employee.
• 14. Birthdate: Date of birth of the employee.
• 15. Coverage Changes: Indicate any changes in coverage status.
• 16. Marital Status: Current marital status of the employee.
• 17. List of Members: Names of all members to be enrolled or affected.
• 18. Authorization: Employee's authorization for information disclosure.
• 19. Certification: Certification of accuracy for the information provided.

If you fail to submit the Dental Enrollment/Change Form, you may experience delays in coverage or an inability to access benefits. Inaccurate submissions can also result in incorrect deductions from your paycheck or loss of benefits during open enrollment periods.

• Coverage Delay: Failure to submit could delay your insurance coverage.
• Incorrect Deductions: Not submitting accurately may lead to incorrect payroll deductions.
• Loss of Benefits: Missed submissions could result in a loss of benefits during enrollment.
• Inaccurate Information: Incorrectly submitted forms raise the risk of errors in your coverage.
• Missed Deadlines: Not adhering to submission timelines may jeopardize your enrollment.

• 1. New Enrollment: Use this form to enroll in dental coverage as a new employee.
• 2. Life Events: Submit for changes due to marriage, divorce, or childbirth.
• 3. Address Change: Update your address information if you move.
• 4. Dependent Changes: Add or remove dependents from your coverage.
• 5. Job Changes: Submit if your job status changes affecting your benefits.