Dental & Vision Coverage
Participant     Participant +1     Participant +2+ (Family)
Dental Coverage Type
PPO    DHMO   (DHMO option only available in CA, NY, NJ, IL, FL, TX)

DHMO Dentist ID#

(DHMO Participants must enter their Primary Care Dentist ID#.)   (What is this?)
 
First Name
Middle Initial
Last Name
Marital Status
Single   Married   Legally Separated   Divorced
Date of Birth
(mm/dd/yyyy)
Gender
   Male   Female
Social Security Number
(no dashes, numbers only)
SAG-AFTRA Member ID
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
User Name
(Used for online access)
Create a log-in Password
(Used for later online access)
Effective Enrollment Date 11/01/2022

DEPENDENT INFORMATION

(Enter dependent information if applicable)

 

NAME

 

SEX

 

RELATIONSHIP

 

SSN (DHMO Only)

 

BIRTH DATE

 

STUDENT

 

DEPENDENT ONE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT TWO INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT THREE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT FOUR INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT FIVE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SIX INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SEVEN INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No


 

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