$1 UnitedHealthcanl

Golden Rule
Insurance Company

PETAR ASANIN
5005 E STEMBER RD
FRUITPORT MI 49415

RE: Policy Number 095-465-075

Dear Petar Asanin:

Thank you for allowing us to serve your dental insurance needs.

The materials included in this packet provide you with important information about your new plan.
Please be sure to review them thoroughly so that you have a good understanding of your plan
and how it works.

ID cards
• You will receive your ID card(s) shortly under separate cover from UnitedHealthcare
Dental.

Dental Preventive Services — No waiting period

• Includes oral evaluations, routine cfeahings and X-fays.

Dental Basic Services - 6 month waiting period

• Includes simple (nonsurgical) extractions, emergency treatment to ease dental pain,
amalgam fillings, resin-based composite fillings, and local anesthesia.

We are pleased to provide you with the protection of this insurance plan. We hope to serve as
your dental insurance provider for many years to come.

SEE REVERSE SIDE FOR IMPORTANT CONTACT INFORMATION

PO Box 31372
Salt Lake City, Utah 84131-0372

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Golden Rule
Insurance Company

PETAR ASANIN
6688 JOLIET RD # 255
COUNTRYSIDE IL 60525-4575

RE: Policy Number 095-465-075

Dear Petar Asanin:

Thank you for allowing us to serve your dental insurance needs.

The materials included in this packet provide you with important information about your new plan.
Please be sure to review them thoroughly so that you have a good understanding of your plan
and how it works.

ID cards
• You will receive your ID card(s) shortly under separate cover from UnitedHealthcare
Dental.

Dental Preventive Services — No waiting period

• Includes oral evaluations, routine cleanings and X-rays.

Dental Basic Services - 6 month waiting period

• Includes simple (nonsurgical) extractions, emergency treatment to ease dental pain,
amalgam fillings, resin-based composite fillings, and local anesthesia.

We are pleased to provide you with the protection of this insurance plan. We hope to serve as
your dental insurance provider for many years to come.

SEE REVERSE SIDE FOR IMPORTANT CONTACT INFORMATION

PO Box 31372
Salt Lake City, Utah 84131-0372
Welcome 0119

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 11715adcf721 Petar Asanin 03-12-2019 7:51:55 AM

MICHIGAN
APPLICATION FOR OENTAL/ VISION INSURANCE
GOLDEN RULE INSURANCE COMPANY — INDIANAPOLIS, INDIANA

0 Female
First Name Middle Initial Last Name Birth Date: Month Day Year Age Gender

Mailing 5005 E Stemberg Rd

Address:

Sjreet (Include Apt.) a

Fruitport MI 494 15
‹ i ' i
Stale ZIP

A physical address is required if different than your mailing address. PO Boxes are not accepted as a physical address.
Physical 5005 E Stemberg Rd
Address:
Street(Include ApL)
Fruitport MI 494 15

City Stale ZIP

Anytime asaninpetar93 gmailcom

Phone Numbers ( 231 ) 788-8222
Horne Other Best number and times to call Email Address

DEPENDENTS: List below any dependents to be covered under the policy.

Name (Last, First, M.I.) Relationship Birth Oate Gender
Swincher Lora

PAYOR:
(If not You): Name

REQUESTED EFFECTIVE DATE: 03-13-2019 (See Sfatemenf o/ Understanding section.)

Plan Choices: O Dental Premier Elite D Dental Premier ChoiceSM
B Dental Prima Sffl D Dental Primary Prefe rredSM
0 Dental Essential*° D Dental Essential Preferred "
OPTIONAL: Q Vision
Payment Mode: B Monthly O Ouarterly
Paymem 0 tions: 0 EFT @ Credit Card

Initial Premium for Mode Chosen* $ 40.12

”The amount charged to your credit card will be the total amount for the payment mode chosen (Monthly,
Ouarterly).
Electronic Funds Transfer (EFT) and Credit Card payments will be collected at the time of application.

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DV-AP-146-GRI-21 975E-G-12t7

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 11715adcf72\ Petar Asanin 03-12-2019 7.5f:55 A/vI

MlCfJlGAN
APPLICATION FOR DENTAL/VISION INSURANCE
GOLDEN RULE INSURANCE COMPANY — INDIANAPOLIS, INDIANA

APPMCANT(S) INFORMATION
PROPOSED Petar Asanin 05-13 @ Male

INSURED: M Female

First flame Middle Initial Last Name Birth Date: Month Day Year Age Gender

Mailing 6688 Joliet Rd #255

Address:
Street (Include Apt.)
Indian Head Park IL 60525
I I I
C‹!y State ZIP

A physical address is required if different titan your mailing address. PO Boxes are not accepted ss a physical address.
Physical 5005 E Stemberg Rd
Address: i i i i i
Street (Include ApL)
F itport MI 4M15
City State ZIP

Ph one Number 231 ) 788-8222 Anytime asaninpetar93@gmail.com

Home Other Best number and limes to call Email Address

DEPENDENTS: List below any dependents to be covered under the policy.

Name (Last, First, M.I.) Relationship Birth Date Gender
Swincher Lora 04-15-1985 @ {\/j @

PAYOR: _
(If not You): Name

Street State

REQUESTED EFFECTIVE DATE: @/-13 -2019 (See Statement o/ Understanding ‹ect/on.j

Plan Choices: Q Dental Premier Elite O Dental Premier Choice u
@ Dental Primal° Q Dental Primary Prefe rred5M
0 Dental Essential D Dental Essential Preferred*"
OPTIONAL: 0 Vision
Payment Mode: @ Monthly @ Quarterly
Payment Options: 0 EFT BCredit Card

Initial Premium for Node Chosen’ @ 40.12

“The amount charged to your credit card will be the total amount for the payment mode chosen (Monthly, Ouaxerly).
Electronic Funds Transfer (EFT) and Credit Card payments will be collected at the time of application.

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