Securian Dental Online Enrollment/Billing Reports User Request Form

Securian Dental Online Enrollment/Billing Reports User Request Form Please review the attached Instructions, Obligations and Termination provisions.

Company Information Date: Group Administrator Name: Company Name: Group Administrator Email: Group Number(s): State: Group Administrator Telephone Number: Requestor Information (Multiple Users Can be Added Below) User #1 User #2 User #3 User #4 Requestor Name Requestor Job Title Is Requestor with Group Group Group Group Group or Broker Broker Broker Broker Broker? Phone Number Email Address A/R Number(s) from Billing Statement (existing customers only) Online Applications Requested Online Enrollment Update Update Update Update Access View Only View Only View Only View Only Online Billing Reports Add as a Group Yes Yes Yes Yes Contact No No No No List Desired Subgroups Below (Indicate “ALL” if specific subgroups are not required) Online Enrollment Billing Reports Complete Only if Request is to Add Applications to Existing Online Profile What is your current User Name?

4/22/2018 Group Administrator Authorization I authorize access to the online tools for the individual(s) listed in the User Information section.

Signature: Date: INSTRUCTIONS:

a) Complete the form in its entirety. If more than four users are required, please complete additional forms as needed. b) The Group Administrator MUST sign and date all requests for Online Application Access. c) Large Group: Email the form to your Large Group Implementation or Account Management contact. d) Small Group: Email the form to [email protected] or fax the form to 1-866-440-8787. e) The user will receive their User Name and Password in an encrypted email.

OBLIGATIONS:

Recipient Party acknowledges the confidential nature of Enrollment, Billing and Subscriber Information and agrees that it shall:

a) not disclose Enrollment, Billing and Subscriber Information to any employees of Recipient Party who do not have a reasonable need for such information in order to accomplish the permitted use;

b) instruct all employees who have access to Billing or Enrollment Information of the necessity to maintain the confidentiality of such information and to comply with applicable confidentiality policies;

c) except as expressly allowed, not disclose, directly or indirectly, in whole or in part, to any third party any Enrollment, Billing and Subscriber without the prior written consent of Securian;

d) cause appropriate proprietary rights and confidentiality notices, markings or legends to be placed upon Billing Information; and

e) maintain reasonable and customary procedures to ensure compliance with the terms of this Agreement.

In addition, Recipient Party agrees to comply with such security measures requested by Securian including but not limited to requirements that individuals accessing Enrollment, Billing and Subscriber Information utilize an identification username and password in doing so.

TERMINATION:

This Agreement shall continue in effect until terminated. Either party may terminate this Agreement at any time by giving written notice thereof to the other party at the address set forth above. Termination shall become effective within 30 days following receipt of the notice or any later date stated in the notice.

The Recipient party’s assumes all responsibility of changes to security and any potential impact due to failure to notify Securian in a timely manner.

Updated 02.23.17