1. I understand that the HFM/Cascade Dental Plan can only accept a limited number of applicants and that priority is given to applicants based on their accss to both resources and dental care. I understand that I (or my child) may be placed on a waiting list if there are not spaces available when my (or my child's) application is received.
2. I understand that until HFM approves my (or my child's) application no coverage will be effective.
3. I understand that I (or my child) am (is) subject to disenrollment and exclusion from this program if this information is false, fraudulent or contains international misrepresentation of facts.
4. I understand that it is my responsibility to inform HFM of any changes that may affect my (or my child's) eligibility, including any dental insurance that I (or my child) may obtain in the future.
5. I understand that if I (or my child) move out of the state of Michigan, I must notify HFM so that I can be dis-enrolled.
6. I understand that annual re-enrollment is necessary in order that my (or my child's) benefits remain active. I understand that if I do not complete the annual re-enrollment application, my (or my child's) enrollment will be terminated.
7. I understand that if I voluntarily dis-enroll myself (or my child) or if I (or my child) am involuntarily dis-enrolled from the HFM/Cascade Dental Plan, I (or my child) may not reapply for at least one year after my (or my child's )coverage ends.
8. I understand that, by signing below, I certify that all information and documentation provided as part of this application are complete, accurate and true to the best of knowledge and belief.