Dental Coverage
None    PPO    DHMO   (DHMO available in CA,CO,FL,IL,IN,MI,MO,NJ,NY,OH)
Vision Coverage
None    VSP   

**Please note that if you are a surviving spouse or dependent of the retiree, use your own social security number, name, date of birth, etc.

First Name
Middle Initial
Last Name
Marital Status
Single Married Legally Separated Divorced Surviving Spouse
Date of Birth
(mm/dd/yyyy)
Gender
   Male Female
Social Security Number
(no dashes, numbers only)

DHMO Dentist ID#

(DHMO Participants must enter their Primary Care Dentist ID#.)   (What is this?)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
Create a log-in Password
(Used for later online access)
Effective Enrollment Date 07/01/2024

ENROLLMENT OF DEPENDENT INSURANCE

(Select Dependent Coverage and enter dependent information if applicable)

 

I Elect Dependent Coverage For:  None   spouse only   spouse & child(ren)   child(ren) only

 

NAME

 

SEX

 

RELATIONSHIP

 

SSN

 

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

 


 

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