STATE OF CALIFORNIA í DEPARTMENT OF PERSONNEL ADMINISTRATION
DENTAL PLAN DIRECT PAYMENT AUTHORIZATION
STD 696 (REV 5/2007)
INSTRUCTIONS: Review General Instructions on the reverse of this form. Then, complete the following parts of this form for employees enrolled in a dental
plan who are going on non-pay status (i.e., the employee will not receive a warrant from the State Controller's Office).
1. Parts A and B and Part D, Item 16-Employees who do not wish to continue dental coverage.
2. Parts A, C and D-Employees who wish to continue dental coverage.
PLEASE TYPE OR PRINT USING BALL POINT PEN
SOCIAL SECURITY NUMBER
(SEE REVERSE FOR DISCLOSURE STATEMENT)
NAME (First, Middle, Last)
3. DATE OF BIRTH
HOME PHONE NUMBER
5. MAILING ADDRESS (Street, City, State, Zip Code)
Check here for 120-day
COVERAGE NOT RETAINED
I do not wish to continue my dental plan coverage while off pay status. I understand my coverage will terminate at
the end of the first full month I am off pay status and will not resume until the beginning of the second month after I
return to pay status.
PREMIUM PAYMENT AGREEMENT
Complete the premium calculations below. Direct payment may not exceed one year for any carrier. Payment must be for a three-month period
or the length of the absence, whichever is less. The initial payment is due to the carrier on the first day of the month following the first full month
the employee is off pay status. Installment and/or final payment(s) (if applicable) will then be due to the carrier on the first of each succeeding
9.A. INITIAL PAYMENT (Submit directly to carrier with this form):
9.B. INSTALLMENT PAYMENT(S) (IF APPLICABLE): $