The Dental Program Administrative Guide was designed to assist campuses with
the administration of CSU Dental Benefits. All necessary forms and contacts have been
General instructions and information pertaining to the administration of dental benefits for the CSU.
Appendix ADental Plan Enrollment Authorization
This section contains the necessary enrollment forms.
Declaration of Domestic Partnership
Statement of Financial Liability for Domestic Partner
Domestic Partner Tax Dependent Certification Form
Domestic Partner Tax Dependent Cancellation Form
Affidavit of Eligibility for Economically Dependent Children
Instructions for completing the Dental Plan Enrollment Authorization Form (STD-692)
Dental Plan Permitting Event Charts
Request for continued Dental Plan coverage and Direct Payment Authorization, or Termination of Enrollment Form
Continuation of coverage information and documents.
Group & Sublocation Numbers
Delta Dental Plan: COBRA Notice, COBRA Form
PMI DeltaCare Dental Plan: COBRA Notice, COBRA Form
List of employee groups eligible for Enhanced Dental Coverage
CSU Benefits Officers
Directory of Dental Plan Contacts
Lecturer Benefits Revised Eligibility
Additions and Deletions Sheet for Administrators, Delta Dental Plan